Audit and feedback: effects on professional practice and healthcare outcomes

Theory-informed refinement and tailored implementation of a quality improvement program in maternity care to reduce unwarranted clinical variation across a health service network

BACKGROUND

Unwarranted clinical variation presents a major challenge in contemporary healthcare, indicating potential inequalities and inefficiencies, and unrealised potential for better outcomes. Despite an increasing focus on unwarranted clinical variation, and consideration of efforts to address this challenge, evidence-based strategies which achieve this are limited. Audit and feedback of healthcare processes (process auditing) and clinician engagement are important tools which may help to reduce unwarranted clinical variation, however their application in maternity care is yet to be thoroughly explored. We describe the development and implementation of a program to address unwarranted clinical variation across a multi-site maternity network termed Practice Improvement with Clinicians eNgaged in Improving Care (PICNIC). The goals of the program were to engage clinicians to identify and reduce unwarranted clinical variation and enhance the delivery of evidence-based care, with the intention of improving care quality, clinical outcomes, and efficiency of the health service.

METHODS

A theory-informed approach was used to design and implement the four-phase program, underpinned by implementation science and quality improvement methodologies. It utilised clinician-performed process auditing, built upon existing evidence for audit and feedback, and employed evidence-based implementation strategies to promote clinician behaviour change.

RESULTS

The intervention was implemented across the five maternity network sites in 2020 with around 300 clinicians participating in 18 audit topics over four years (2020-2023). A diverse array of evidence-based strategies were utilised to support implementation over this period and are mapped to the Behaviour Change Taxonomy and Expert Recommendation for Implementing Change (ERIC) compilation. Observed benefits of the program include the development and implementation of clinician co-designed system-level improvements that are tailored to context, to improve the delivery of best-practice healthcare and improve outcomes.

CONCLUSIONS

Implementation science theory and quality improvement processes can be integrated pragmatically to engage clinicians to address unwarranted clinical variation, with the objective of creating meaningful behaviour change, and system-level improvements for better healthcare outcomes. The replicability of this approach in other disciplines and hospital networks should be explored.

TRIAL REGISTRATION

Not applicable to this report.

Development and usability testing of a multifaceted intervention to reduce low-value injury care

BACKGROUND

Multifaceted interventions that address barriers and facilitators have been shown to be most effective for increasing the adoption of high-value care, but there is a knowledge gap on this type of intervention for the de-implementation of low-value care. Trauma is a high-risk setting for low-value care, such as unnecessary diagnostic imaging and the use of specialized resources. The aim of our study was to develop and assess the usability of a multifaceted intervention to reduce low-value injury care.

METHODS

We used the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change tool as theoretical foundations to identify barriers and facilitators, and strategies for the reduction of low-value practices. We designed an initial prototype of the intervention using the items of the Template for Intervention Description and Replication. The prototype's usability was iteratively tested through four focus groups and four think-aloud sessions with trauma decision-makers (n = 18) from seven Level I to Level III trauma centers. We conducted an inductive analysis of the audio-recorded sessions to identify usability issues and other barriers and facilitators to refine the intervention.

RESULTS

We identified barriers and facilitators related to individual characteristics, including knowledge and beliefs about low-value practices and the de-implementation process, such as the complexity of changing practices and difficulty accessing performance feedback. Accordingly, the following intervention strategies were selected: involving governing structures and leaders, distributing audit & feedback reports on performance, and providing educational materials, de-implementation support tools and educational/facilitation visits. A total of 61 issues were identified during the usability testing, of which eight were critical, 33 were moderately important, and 18 were minor. These issues led to numerous improvements, including the addition of information on the drivers and benefits of reducing low-value practices, changes in the definition of these practices, the addition of proposed strategies to facilitate de-implementation, and the tailoring of educational/facilitation visits.

CONCLUSIONS

We designed and refined a multifaceted intervention to reduce low-value injury care using a process that increases the likelihood of its acceptability and sustainability. The next step will be to evaluate the effectiveness of implementing this intervention using a pragmatic cluster randomized controlled trial.

TRIAL REGISTRATION

This protocol has been registered on ClinicalTrials.gov (February 24th 2023, #NCT05744154, https://clinicaltrials.gov/ct2/show/NCT05744154 ).

Pilot Study of a Modified DOPS Scale for Insulin Pump and CGM Installation Training in Chinese Medical Students During Endocrinology Rotations

Background

Direct Observation of Procedural Skills (DOPS) is a clinical assessment tool that enables trainers to observe medical students' procedural abilities in real-time clinical settings. It assesses students' knowledge application, decision-making, and skill proficiency during clinical tasks.

Methods

This study modifies the DOPS to evaluate the operation of insulin pumps (PUMP) and continuous glucose monitoring systems (CGMS) in diabetes management. Key elements of the modified DOPS include 1) Knowledge Assessment: Evaluating understanding of PUMP and CGMS, including interpreting CGMS data for insulin adjustments; 2) Operational Skills: Assessing correct PUMP needle insertion, programming, and adjustments; 3) Patient Safety: Ensuring safe and aseptic procedures; 4) Feedback: Providing constructive feedback to help students improve their skills.

Results

Training through DOPS led to significant improvements in all domains, overall performance scores, and reduced execution time for each domain. Correlations between domains showed that PUMP indication scores were linked to all other domains and execution times, including re-evaluation. Communication skills and seeking assistance were crucial factors influencing other domains. Multilinear regression analysis revealed that while DOPS-CGMS (R square 1.0) fully explained performance scores, DOPS-PUMP (R square 0.984) indicated that additional personal qualities significantly impacted students' PUMP operation performance.

Conclusion

This customized DOPS form offers insights into students' abilities in managing diabetes with PUMP and CGMS, while emphasizing the need for training on both technical skills and interpersonal skills in future educational models.

Long-Term Outcomes of a Health Information System-Based Feedback Intervention Study of Antimicrobial Prescriptions in Primary Care Institutions: Follow-Up of a Randomized Cross-Over Controlled Trial

Purpose

To evaluate the long-term impacts of the feedback intervention on controlling inappropriate use of antimicrobial prescriptions in primary care institutions in China, as a continuation of the previous feedback intervention trial.

Methods

After the intervention ended, we conducted a 12-month follow-up study. The prescription data were collected from the baseline until the end of the follow-up period. The generalized estimation equation was employed to analyze the differences among four representative time points: at the baseline point, at 3 months, at 6 months, and at 18 months. The time-intervention interaction was utilized to evaluate the changing trends of group A and group B. Our primary outcome variable is the monthly inappropriate antimicrobial prescription rate (IAPR).

Results

After adjusting for covariates, the IAPRs in group A decreased by 1.00% on average from the baseline point to the 3 months, 5.00% from the 3 months to the 6 months, -0.92% from the 6 months to the 18 months, and 0.39% from the baseline point to the 18 months. During the corresponding four periods in group B, the average decline was 2.33%, 3.67%, -0.42%, and 0.72%, respectively. As for antimicrobial prescription rates (APRs), the average decline for group A was 1.33%, 3.67%, and 0.17% during the three periods: from the baseline point to the 3 months, from the 3 months to the 6 months, and from the 6 months to the 18 months, respectively. Accordingly in group B, the average decline was 1.00%, 3.67%, and 0.08%, respectively.

Conclusion

Our feedback intervention generated limited long-term impacts. Although the IAPRs and the APRs consistently remained below the baseline point, both rates experienced a rebound within a certain range following the stop of the intervention in the two groups. It is reasonable to think that the desired effects will be difficult to maintain without sustained implementation of feedback intervention.

Audit and feedback is an effective implementation strategy to increase fidelity to a multi-component labor induction protocol designed to reduce obstetric inequities

BACKGROUND

Studies have demonstrated that standardizing labor induction (IOL), often with the use of protocols, may reduce racial inequities in obstetrics. IOL protocols are complex, multi-component interventions. To target identified implementation barriers, audit and feedback (A&F) was selected as an implementation strategy. Here, we aimed to understand the acceptability and effect of A&F on fidelity to this complex intervention through quantitative and qualitative approaches.

METHODS

This secondary analysis of a type I hybrid effectiveness-implementation trial (10/2018-12/2022) compared 2 years before (PRE) to 2 years after (POST) implementation of an IOL protocol at two sites. Fidelity to each of 8 specific protocol components was collected via chart review. During the POST period, unit-aggregated A&F reports were distributed via email every 3 months to site clinicians. Reports tracked fidelity to protocol components over time. For this analysis, we compared component fidelity PRE to POST-implementation. Additionally, during the POST period, we compared fidelity by month after each A&F (Month#1 v. Month#2/3) to evaluate the effect of A&F over time. Acceptability of A&F reports was evaluated using qualitative interviews.

RESULTS

8509 labor inductions were included (PRE = 4214, POST = 4295). A&F reports were successfully distributed every 3 months for the 2-year POST period. PRE to POST-implementation, fidelity to 4 of the 8 components increased significantly (cervical Foley utilization, latent labor examination frequency, amniotomy timing, and intrauterine pressure catheter utilization), without change in the other 4 components. For 2 of those 4 components where improvement was noted, there was no difference in fidelity by month after A&F report; rather, there was sustained improvement across the POST-implementation period. On the other hand, for the remaining 2 components, fidelity peaked in the first month after each A&F report, with some decline in the following 2 months prior to the next A&F report. Qualitative analysis (n = 24) supported A&F acceptability, with A&F described as "motivating" and "helpful."

CONCLUSIONS

A&F was an effective implementation strategy to promote fidelity to certain components of this labor induction protocol. With some decline in effect after the first month POST-A&F report, increased A&F frequency should be considered in future work targeting obstetric outcomes, as well as health inequities.

Addressing Late-arriving Surgeons in Support of First-case On-time Starts

Introduction

First-case on-time starts (FCOTS) is an established metric of perioperative efficiency, impacting global perioperative throughput. Late-arriving surgeons are a common cause of late operating room (OR) starts. This project reflects a quality improvement effort to reduce late surgeon arrivals by 30% for 24 months and improve FCOTS.

Methods

A multidisciplinary perioperative leadership team developed clear expectations, including tracking, roles, review processes, and consequences. These were broadly communicated among stakeholders, and feedback was incorporated. A new same-day surgeon-to-surgeon feedback mechanism was instituted for late surgeon arrivals, allowing for surgeon feedback and reiteration of expectations. Results were prospectively tracked for 24 months before and following implementation.

Results

Late surgeon arrivals decreased by 45%, from 23.6 to 13 per month for 24 months before and following implementation, respectively (P < 0.001). Balancing measures did not see increases for the same periods. FCOTS increased from 66% to 72% postimplementation (P < 0.001). Statistical process control P-charts demonstrated centerline shifts for both metrics.

Conclusions

Development and communication of a clear framework of expectations, review, and consequences, with ongoing monitoring, clear performance expectations, and timely feedback, can reduce late surgeon arrival and improve FCOTS. Direct and timely communication provided immediate feedback to late surgeons and indicated reporting errors, providing more accurate data on late starts. Consistent policy enforcement is critical for credibility.

Improving audit and feedback: A user-centred approach to designing feedback techniques for an online experiment

Objective: Audit and feedback (A&F) programmes aim to improve patient care by providing summary data on performance to clinicians. They generally have modest, but variable, effects on patient care and questions remain about how best to provide performance feedback. It is not feasible to test all ways of providing feedback in 'real-world' randomised trials. Online screening experiments that screen feedback techniques prior to real-world evaluations of optimised versions offer a systematic approach. User-centred design methodologies can inform the design of such online experiments. Methods: We report the use of an innovative user-centred design approach to create feedback techniques for an online screening experiment and reflect on its usefulness. This approach included the involvement of patients and stakeholders. Results and Conclusion: We highlight lessons on ways to engage with partners, considering the feasibility of online A&F feedback delivery, fidelity, and usability. We demonstrate how the approach was implemented to co-create a set of feedback techniques for an online experiment and could also be applied to the design of other digital interventions.

Features and effectiveness of electronic audit and feedback for patient safety and quality of care in hospitals: A systematic review

Background: Increasing digitisation in healthcare is flowing through to quality improvement strategies, like audit and feedback. Objectives: To systematically review electronic audit and feedback (e-A&F) interventions in hospital settings, examining contemporary practices and quantitatively assessing the relationship between features and effectiveness. Methods: We performed a systematic review using a structured search strategy from 2011 to July 2022. Searches yielded a total of 5095 unique publications, with 152 included in a descriptive synthesis, reporting publication characteristics and practices, and 63 in the quantitative synthesis, to evaluate the effect size of intervention features. Results: The search returned publications across characteristics, including countries of origin, feedback topics, target health professionals, and study design types. We also identified an association with effectiveness for all but one of the features examined, with a Cohen's d ranging from above +0.8 (a large positive effect), to -0.67 (a medium negative effect). Socio-technical features related to supportive organisations and the involvement of engaged health professionals were most associated with effective interventions. Conclusion: Key findings have confirmed that a common set of features of e-A&F systems can influence effectiveness. Results provide practitioners with insight into where resources should be focused during the implementation of e-A&F.

Changing or validating physician opioid prescribing behaviors through audit and feedback and academic detailing interventions in primary care

Background

In Ontario, Canada, province-wide initiatives supporting safer opioid prescribing in primary care include voluntary audit and feedback reports and academic detailing. In this process evaluation, we aimed to determine the fidelity of delivery and receipt of the interventions, the observed change strategies used by physicians, potential mechanisms of action, and how complementary the initiatives can be to each other.

Method

Semi-structured interviews were conducted with academic detailers and with physicians who received both interventions. Academic detailer interviews were coded using the Behavior Change Technique Taxonomy; physician interviews were coded to the Theoretical Domain Framework. Change strategies were summarized based on academic detailer intentions and physician-reported practice changes. Potential mechanisms of action were identified using the Theories and Techniques Tool and the literature. Patient partners informed the interpretation of results through ongoing group discussions of preliminary findings.

Results

Interviews were conducted with eight academic detailers and 12 physicians. Change strategies described by academic detailers to support physicians' opioid prescribing included problem solving, instructions on how to perform the behavior, adding objects to the environment, credible source, shaping knowledge, and social support. Physicians mentioned that academic detailing validated current opioid practices or increased their belief about capabilities and their intentions, mediated by increased skills and the impact of environmental context and resources. Potential mechanisms of action included behavioral regulation, behavioral cueing, and general attitudes/beliefs. On its own, receiving the audit and feedback report did not lead to changes in beliefs about prescribing practices; however, for some physicians, it provided validation and reassurance. Physicians saw unrealized potential for complementarity.

Conclusions

New interventions are often implemented in a complex ecosystem with other competing interventions. In this study, we show how examining the fidelity of the intervention from initial design through to delivery can identify opportunities for potential optimization.

Generating and translating evidence for safe and effective medication management in aged care homes

Generating and translating high-quality evidence is integral to providing safe and effective medication management for residents of aged care homes. Residents are often under-represented in trials of medication effectiveness and safety. This paper reviews opportunities and challenges for generating and translating evidence for safe and effective medication management in aged care homes. There are an increasing number of randomized controlled trials (RCTs) being conducted in aged care homes. Observational studies can also help address the evidence-practice gap arising from underrepresentation of residents in RCTs. Stepped-wedge and helix counterbalanced designs may help overcome limitations of traditional RCTs for evaluating medication management interventions in the aged care setting. Strategies for generating evidence include building effective partnerships with aged care homes and organizations, using novel trial designs, leveraging existing data and knowledge sharing through international platforms. Strategies for translating evidence include using quality indicators for audit and feedback, provision of education and training, engaging internal and external stakeholders, and development of local action plans and guideline implementation tools. There is an emerging interest in the role of knowledge brokers to facilitate knowledge translation. Future directions for generating and translating evidence include strengthening international research collaboration, industry partnerships, standardizing aged care home data to support national and international comparisons, and optimizing the use of technology. Initiatives may include improving access to routinely collected administrative health and medication data for conducting high-quality observational studies. Future studies should assess outcomes prioritized by residents to ensure that medication management strategies are tailored to their needs.

The role of guideline organizations in nationwide guideline implementation: a qualitative study

BACKGROUND

Research indicates suboptimal uptake and impact of clinical practice guidelines in Dutch healthcare. Dutch guideline organizations, i.e. guideline developers, governmental agencies, health insurers and other national organizations, develop, authorize and/or support the use of guidelines in Dutch clinical practice. These organizations influence the end users' awareness, accessibility, understanding, acceptability and applicability of guidelines and, therefore, play a crucial role in guideline implementation. This study explores how they plan, execute, monitor and evaluate guideline dissemination and implementation.

METHODS

Utilizing a qualitative design, we conducted semi-structured interviews with 35 participants from 24 guideline organizations. We conducted framework analysis, using theories on guideline implementation planning, the 'taxonomy of strategies for achieving guideline implementation and compliance' and the principles of logic models to analyse the data.

RESULTS

Most guideline organizations made limited use of implementation planning approaches that are known to enhance guideline uptake and impact. These approaches include pre-identifying implementation barriers, engaging stakeholders and applying implementation theories, models and frameworks to select and tailor implementation strategies. Instead, they primarily relied on a standard set of predominantly dissemination and occasional implementation strategies known to be practical in terms of ease, cost and time. Commonly used implementation strategies included distributing, advertising and presenting guideline materials, along with providing additional implementation supporting materials. Regarding monitoring and evaluation methods, few organizations assessed the process, outcome or impact of guideline implementation. Those that did primarily relied on clinical peer review and benchmark information for their assessments.

CONCLUSIONS

While Dutch guideline organizations recognized and endorsed the importance of implementation, this did not consistently translate into tailored implementation actions. Most guideline organizations did not have an integrated, structural and well-thought-out plan for implementation. The lack of regular, structured monitoring and evaluation raised uncertainties about the effectiveness of implementation in supporting end users and improving patient outcomes. Suggested follow-up research and practice enhancements could strengthen central-level implementation efforts, fostering more effective local implementation and, ultimately, improving health outcomes.

Benchmarks for low back pain in general practice in Flanders: electronic audit of INTEGO

BACKGROUND

Low back pain (LBP) is one of the most frequent reasons for encounter in general practice. Yet results from literature show adherence to clinical practice guidelines is low. Audit & feedback is a well-known strategy to improve adherence to guidelines. Benchmarking is an important step in the audit & feedback process. The objective of this study was to develop data-derived benchmarks for low back pain quality indicators.

METHODS

Four electronic health record extractable quality indicators were selected from an existing indicator set developed by CEBAM, an independent, multidisciplinary and interuniversity medical scientific institute in Belgium. Data from 2021-2022 from INTEGO, a general practice morbidity registry, were used to calculate benchmarks for the four quality indicators. The Achievable Benchmark of Care methodology was used to create benchmarks based on the performance of the 10% best-performing practices.

RESULTS

The following benchmarks were derived: 4.2% prescription for medical imaging, 12.7% prescription for opioids, 27.2% for prescription for non-steroidal anti-inflammatory drugs or acetaminophen, 37.7% prescription for physical therapy and 11.9% prescription for work absenteeism.

CONCLUSIONS

Benchmarks for four electronic health record-extractable quality indicators have been established. They can be used for an electronic audit & feedback tool in primary practice in Flanders or other quality improvement initiatives.

Extending the Calgary Audit and Feedback Framework into the virtual environment: a process evaluation and empiric evidence

BACKGROUND

The Calgary Audit and Feedback Framework (CAFF) is a pragmatic, evidence-based approach for the design and implementation of in-person social learning interventions using Audit and Group Feedback (AGF). This report describes extension of CAFF into the virtual environment as part of a multifaceted intervention bundle to reduce redundant daily laboratory testing in hospitals. We evaluate the process of extending CAFF in the virtual environment and share resulting evidence of participant engagement with planning for practice change.

METHODS

We describe an innovative virtually facilitated AGF intervention based on the CAFF. The AGF intervention was part of an intervention bundle which included individual physician laboratory test utilization reports and educational tools to reduce redundant daily laboratory testing in hospitals. We used data from recorded and transcribed virtual AGF sessions, post AGF session surveys and detailed field notes maintained by project team members. We used simple descriptive statistics for quantitative data and analyzed qualitative data according to the elements of CAFF.

RESULTS

Eighty-three physicians participated over twelve virtual AGF sessions conducted across four tertiary care hospitals during the study period. We demonstrate that all prerequisite activities for CAFF (relationship building, question choice and data representation) were present in every virtual AGF session. Virtual facilitation was effective in supporting the transition of participants through different steps of CAFF in each session to lead to change talk and planning. All participants contributed to discussion during the AGF sessions. The post AGF session surveys were filled by 66% of participants (55/83), with over 90% of respondents reporting that the session helped them improve practice. 46% of participants (38/83) completed personal commitment to change forms at the end of the sessions.

CONCLUSIONS

Virtual AGF sessions, developed and implemented with fidelity to the CAFF approach, successfully engaged physicians in a group learning environment that led to change planning. Further studies are needed to determine the generalizability of our findings and to add to the literature on evidence-based virtual facilitation techniques.

Effect of a Feedback Visit and a Clinical Decision Support System Based on Antibiotic Prescription Audit in Primary Care: Multiarm Cluster-Randomized Controlled Trial

BACKGROUND

While numerous antimicrobial stewardship programs aim to decrease inappropriate antibiotic prescriptions, evidence of their positive impact is needed to optimize future interventions.

OBJECTIVE

This study aimed to evaluate 2 multifaceted antibiotic stewardship interventions for inappropriate systemic antibiotic prescription in primary care.

METHODS

An open-label, cluster-randomized controlled trial of 2501 general practitioners (GPs) working in western France was conducted from July 2019 to January 2021. Two interventions were studied: the standard intervention, consisting of a visit by a health insurance representative who gave prescription feedback and provided a leaflet for treating cystitis and tonsillitis; and a clinical decision support system (CDSS)-based intervention, consisting of a visit with prescription feedback and a CDSS demonstration on antibiotic prescribing. The control group received no intervention. Data on systemic antibiotic dispensing was obtained from the National Health Insurance System (Système National d'Information Inter-Régimes de l'Assurance Maladie) database. The overall antibiotic volume dispensed per GP at 12 months was compared between arms using a 2-level hierarchical analysis of covariance adjusted for annual antibiotic prescription volume at baseline.

RESULTS

Overall, 2501 GPs were randomized (n=1099, 43.9% women). At 12 months, the mean volume of systemic antibiotics per GP decreased by 219.2 (SD 61.4; 95% CI -339.5 to -98.8; P<.001) defined daily doses in the CDSS-based visit group compared with the control group. The decrease in the mean volume of systemic antibiotics dispensed per GP was not significantly different between the standard visit group and the control group (-109.7, SD 62.4; 95% CI -232.0 to 12.5 defined daily doses; P=.08).

CONCLUSIONS

A visit by a health insurance representative combining feedback and a CDSS demonstration resulted in a 4.4% (-219.2/4930) reduction in the total volume of systemic antibiotic prescriptions in 12 months.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04028830; https://clinicaltrials.gov/study/NCT04028830.

Transforming community-based primary health care delivery through comprehensive performance measurement and reporting: examining the influence of context

BACKGROUND

Community-based primary health care represents various community-based health care (CBPHC) models that incorporate health promotion and community development to deliver first-contact health services. Learning health systems (LHSs) are essential for improving CBPHC in which feedback from relevant stakeholders is used to continuously improve health systems with the goal of achieving population health and health equity. Performance reporting is one way to present data to clinicians and decision makers to facilitate a process of reflection, participation, and collaboration among partners to improve CBPHC.

METHODS

Our objective was to obtain feedback on a regional CBPHC performance portrait through key informant interviews. We used purposive convenience sampling to recruit participants who were clinicians in primary care and/or decision-makers in primary care at a regional level. The performance portrait summarized results of survey questions asked of patients, providers, and primary care organizations. The portrait was organized by the 10 pillars of the Patient's Medical Home (PMH) model. Interview questions specifically asked about portrait content, formatting, interpretability, utility, and dissemination strategies. Content analysis was used to analyze interview data.

RESULTS

We completed 19 interviews with key informants from the Canadian provinces of Nova Scotia (n = 8), Ontario (n = 6) and British Columbia (n = 5). We coded transcripts into four content areas: (1) Usability as influenced by content and interpretability, (2) Formatting, (3) Utility, and (4) Dissemination. Using data and reporting back to clinicians and decision-makers about how their practices and jurisdictions are performing in primary care in meaningful ways is important. Our results suggest having available methodology notes, including the analysis used to develop any scoring, sampling and sample sizes, and interpretation of the statistics is necessary.

CONCLUSIONS

This research was the first to create a comprehensive performance portrait using data driven by factors that are important to primary care partners. We obtained important feedback on the portrait in the context of usability, formatting, utility, and dissemination. This data needs to be used to provide feedback in continuous cycles to evaluate and improve CBPHC models as part of a LHS.

Variation in Case Exposure During Internal Medicine Residency

Importance

Variation in residency case exposure affects resident learning and readiness for future practice. Accurate reporting of case exposure for internal medicine (IM) residents is challenging because feasible and reliable methods for linking patient care to residents are lacking.

Objective

To develop an integrated education-clinical database to characterize and measure case exposure variability among IM residents.

Design, Setting, and Participants

In this cohort study, an integrated educational-clinical database was developed by linking patients admitted during overnight IM in-hospital call shifts at 5 teaching hospitals to senior on-call residents. The senior resident, who directly cares for all overnight IM admissions, was linked to their patients by the admission date, time, and hospital. The database included IM residents enrolled between July 1, 2010, and December 31, 2019, in 1 Canadian IM residency. Analysis occurred between August 1, 2023, and June 30, 2024.

Main Outcomes and Measures

Case exposure was defined by patient demographic characteristics, discharge diagnoses, volumes, acuity (eg, critical care transfer), medical complexity (eg, Charlson Comorbidity Index), and social determinants of health (eg, from long-term care). Residents were grouped into quartiles for each exposure measure, and the top and bottom quartiles were compared using standardized mean difference (SMD). Variation between hospitals was evaluated by calculating the SMD between the hospitals with the highest and lowest proportions for each measure. Variation over time was assessed using linear and logistic regression.

Results

The integrated educational-clinical database included 143 632 admissions (median [IQR] age, 71 [55-83] years; 71 340 [49.7%] female) linked to 793 residents (median [IQR] admissions per shift, 8 [6-12]). At the resident level, there was substantial variation in case exposure for demographic characteristics, diagnoses, volumes, acuity, complexity, and social determinants. For example, residents in the highest quartile had nearly 4 times more admissions requiring critical care transfer compared with the lowest quartile (3071 of 30 228 [10.2%] vs 684 of 25 578 [2.7%]; SMD, 0.31). Hospital-level variation was also significant, particularly in patient volumes (busier hospital vs less busy hospital: median [IQR] admissions per shift, 10 [8-12] vs 7 [5-9]; SMD, 0.96). Over time, residents saw more median (IQR) admissions per shift (2010 vs 2019: 7.6 [6.6-8.4] vs 9.0 [7.6-10.0]; P = .04) and more complex patients (2010 vs 2019: Charlson Comorbidity Index ≥2, 3851 of 13 762 [28.0%] vs 2862 of 8188 [35.0%]; P = .03), while working similar shifts per year (median [IQR], 11 [8-14]).

Conclusions

In this cohort study of IM residents in a Canadian residency program, significant variation in case exposure was found between residents, across sites, and over time.

A qualitative study on the facilitators and barriers to adopting the N-of-1 trial methodology as part of clinical practice: potential versus implementation challenges

PURPOSE

To investigate opinions among healthcare stakeholders whether implementation of the N-of-1 trial approach in clinical practice is a feasible way to optimize evidence-based treatment results for unique patients.

METHODS

We interviewed clinicians, researchers, and a patient advocate (n = 13) with an interest in or experience with N-of-1 trials on the following topics: experience with N-of-1, measurement, validity and reliability, informally gathered data usability, and influence on physician-patient relationship. Interviews were analysed using qualitative, thematic analysis.

RESULTS

The N-of-1 approach has the potential to shift the current healthcare system towards embracing personalized medicine. However, its application in clinical practice carries significant challenges in terms of logistics, time investment and acceptability. New skills will be required from patients and healthcare providers, which may alter the patient-physician relationship. The rise of consumer technology enabling self-measurement may leverage the uptake of N-of-1 approaches in clinical practice.

CONCLUSIONS

There is a strong belief that the N-of-1 approach has the potential to play a prominent role in transitioning the current healthcare system towards embracing personalized medicine. However, there are many barriers deeply ingrained in our healthcare system that hamper the uptake of the N-of-1 approach, making it momentarily only interesting for research purposes.

Implementing ward-based practice books to increase the amount of practice completed during inpatient stroke rehabilitation: a mixed-methods process evaluation

PURPOSE

Stroke survivors must complete large amounts of practice to achieve functional improvements but spend many hours inactive during their rehabilitation. We conducted a mixed methods process evaluation exploring factors affecting the success of a 6-month behaviour change intervention to increase use of ward-based practice books.

METHODS

Audits of the presence, quality and use of ward based-practice books were conducted, alongside focus groups with staff (n = 19), and interviews with stroke survivors (n = 3) and family members (n = 4). Quantitative data were analysed descriptively. Focus group and interview transcripts were analysed using qualitative analysis.

RESULTS

Personal (patient-related) factors (including severe weakness, cognitive and communication deficits of stroke survivors), staff coaching skills, understanding and beliefs about their role, affected practice book use. Staff turnover, nursing shift work and a lack of action planning reduced success of the behaviour change intervention.

CONCLUSIONS

Staff with the necessary skills and understanding of their role in implementing ward practice overcame personal (patient-related) factors and assisted stroke survivors to successfully practice on the ward. To improve success of the intervention, repeated training of new staff is required. In addition to audit and feedback, team action planning is needed around the presence, quality, and use of ward practice books.

The use of patient-reported outcome measures to improve patient-related outcomes - a systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) provide invaluable information on patients' health outcomes and can be used to improve patient-related outcomes at the individual, organizational and policy levels. This systematic review aimed to a) identify contemporary applications and synthesize all evidence on the use of PROMs in these contexts and b) to determine characteristics of interventions associated with increased effectiveness.

METHODS

Five databases were searched for studies providing quantitative evidence of the impact of PROM interventions. Any study design was permitted. An overall benefit (worsening) in outcome was defined as a statistically significant improvement (deterioration) in either a PROM, patient-reported experience measure or clinical outcome. Study quality was assessed using the Effective Public Healthcare Panacea Project's Quality Assessment Tool for Quantitative Studies. A narrative synthesis was conducted.

RESULTS

Seventy-six studies of the 11,121 articles identified met the inclusion criteria. At the individual level, 10 (43%) of 23 studies that fed back PROMs to the patient or healthcare provider showed an improvement in outcome. This percentage increased in studies which used PROMs to monitor disease symptoms and linked these to care-pathways: 17 (68%) of 25 studies using this mechanism showed an improvement. Ten (71%) of 14 studies using PROMs to screen for disease found a benefit. The monitoring and screening approach was most effective using PROMs covering cancer-related, depression and gastro-intestinal symptoms. Three studies found that the mere collection of PROMs resulted in improved outcomes. Another three studies used PROMs in decision aids and found improved decision quality. At the organizational/policy level, none of the 4 studies that used PROMs for benchmarking found a benefit. The three studies that used PROMs for in-depth performance analyses and 1 study in a plan-do-study-act (PDCA) cycle found an improvement in outcome. Studies employing disease-specific PROMs tended to observe improved outcomes more often. There are concerns regarding the validity of findings, as studies varied from weak to moderate quality.

CONCLUSIONS

The use of PROMs at the individual level has matured considerably. Monitoring/screening applications seem promising particularly for diseases for which treatment algorithms rely on the experienced symptom burden by patients. Organizational/policy-level application is in its infancy, and performance evaluation via in-depth analyses and PDCA-cycles may be useful. The findings of this review may aid stakeholders in the development and implementation of PROM-interventions which truly impact patient outcomes.

The effectiveness of a multi-domain electronic feedback report on the performance of quality indicators for chronic conditions: Protocol for a randomized controlled trial in general practice

BACKGROUND

Chronic conditions are a significant public health concern due to their rising prevalence, association with high mortality, and substantial healthcare costs. General practitioners play a crucial role in managing these conditions, and quality indicators are essential tools for assessing the quality of care. Electronic feedback reports incorporating quality indicator performance have shown promise in improving care quality. However, most studies have focused on single conditions or link feedback to financial incentives, which may not sustain long-term practice changes. This study aims to evaluate the effectiveness of a multi-condition electronic feedback reports on quality indicator performance in Swiss general practice without financial incentives.

METHODS

This randomized controlled trial involves general practitioners enrolled in the FIRE project, a database of electronic medical records from Swiss primary care. Participants are randomized to receive either a plain feedback report or a comprehensive quality indicator -specific feedback report bi-monthly for 12 months. The plain feedback report contains descriptive summaries of practice activities, while the quality indicator-specific feedback report includes performance data on 14 quality indicators across cardiovascular, endocrine, pulmonary, and renal domains. The quality indicators were selected in multi-step process involving review of the literature and clinical guidelines, domain expert consultations, and a panel discussion with general practitioners. The primary study objective is to compare the effectiveness of the quality indicator-specific feedback report and of the plain feedback report with respect to the performance of the selected quality indicators.

CONCLUSION

The study addresses a critical gap by evaluating a multi-condition feedback report without financial incentives. Its findings can inform future health policies and strategies, in line with national and international initiatives that promote or even require the implementation of quality measurement activities in general practice.

TRIAL REGISTRATION

Trial registry: ISRCTN. Registration number: ISRCTN10637092, https://www.isrctn.com/ISRCTN10637092. Registered January 9, 2024.

Physician perspectives of clinical performance feedback and impact on well-being: a qualitative exploration

OBJECTIVES

Providing clinical performance feedback to physicians is an established method to improve care, but the impact on physician well-being is unclear. This evaluation aimed to better understand physician perspectives on clinical feedback and its potential impact on well-being.

DESIGN

A qualitative design using semi-structured interviews was undertaken. Data were analysed via consensus coding using an inductive-deductive approach informed by Clinical Performance Feedback Intervention Theory. Findings were used to develop a novel framework describing the relationship between feedback and well-being.

SETTING

Interviews were conducted in a large academic medical centre from June-September 2021.

PARTICIPANTS

We conducted 25 semi-structured interviews with general outpatient and inpatient paediatricians and internists.

RESULTS

Physicians felt that feedback supported well-being based on its perceived purpose (intended to promote professional growth vs serving an alternative purpose), which they discerned based on feedback content (aligned with physician priorities vs not aligned), validity (accurate vs inaccurate), actionability (specific vs not, within a physician's sphere of control vs not) and delivery (supportive vs punitive). The Clinical Performance Feedback Well-Being Model is presented to understand how feedback and recipient variables impact well-being.

CONCLUSIONS

Attention to the process and content of physician clinical performance feedback may advance both the quality of care and physician well-being.

Perceptions and Use of Automated Hospital Outcome Data by EMS Providers: A Pilot Study

Background

Our primary objective evaluated the perception of emergency medical service (EMS) providers' review of automated hospital outcome data. Secondarily, we assessed participation in outcome review as a means of microlearning to obtain continuing education (CE).

Methods

From October-December 2023, three high-volume EMS systems participated in a three-part intervention with results evaluated using a mixed-methods approach. First, EMS providers (emergency medical technicians and paramedics) were invited, via their electronic health record (EHR), to complete a presurvey evaluating their perceptions of reviewing outcomes. Then, EMS providers were notified about the opportunity to earn CE via a microlearning intervention, offering Commission on Accreditation for Pre-Hospital Continuing Education (CAPCE)-approved CE hours for completion of outcome reviews and associated learning modules. Finally, EMS providers were invited to complete a post-survey mirroring the pre-survey. Qualitative analyses identified themes among open-ended responses. Quantitative analyses examined perceptions between pre- and post- surveys.

Results

Of 843 providers contacted, 217 responded to the pre-survey (25.7%). The most endorsed rationale for reviewing outcomes included improving clinical knowledge (95%), improving patient care (94%), and knowing whether care made a difference (93%). Nearly all (91%) reported being more likely to review outcomes if CE were awarded. Among the 67 who completed the open-ended items, the three dominant themes included enhance personal confidence and competence (43%); acquire personal knowledge (39%); and operations (21%). Of 211 providers who participated in the intervention, 56 (27%) were awarded CE. A total of 152 providers responded to the post-survey, and the percentage who agreed that reviewing outcomes improves job satisfaction rose from 89% to 95% between pre- and post-surveys (P = 0.05).

Conclusion

EMS providers supported the personal and professional development and patient care improvement of reviewing patients' outcomes with associated CE. Further study is warranted to evaluate the generalizability of these findings and the best user experience.

Overview of a national endoscopy database: The Trans.IT database and its impact on data registration quality

BACKGROUND

The Trans.IT database is a national gastrointestinal (GI) endoscopy database developed in 2012. It automatically collects anonymous data from GI endoscopy procedures in a centralized database. All endoscopists use a structured reporting tool for uniform data collection. In this study, we aim to provide an overview of the database and to evaluate its impact on data registration quality.

METHODS

We used all ERCPs, colonoscopies and colorectal cancer (CRC)-screening colonoscopies performed between 2016 and 2020. We excluded centers joining after 2016 and patients below age 18. Data registration quality for ERCPs included completeness of data for: intention of ERCP, Schutz score, ASA classification, papillary status (virgin or previous sphincterotomy), cannulation (success or failure to cannulate the desired duct) and procedural success. For colonoscopies: indication, ASA-classification, Boston Bowel Preparation Score (BBPS), cecal intubation, polyp detection rate (PDR). For CRC-screening colonoscopies, ASA-classification, BBPS, cecal intubation, PDR and adenoma detection rate (ADR).

RESULTS

A total of 14,156 ERCPs, 150,962 colonoscopies and 37,199 colorectal cancer screening colonoscopies were included in our analysis. For ERCPs, registration of procedural intention, Schutz score, ASA classification, papillary status, cannulation and procedural success improved from 34.9%, 32.7%, 72.6%, 36.5%, 34.6%, 27.2% in 2016, to 86.4%, 84.6%, 97.4%, 86.4%, 82.1%, 84.0%, respectively, in 2020. For non-screening colonoscopies, registration of indication, ASA classification, BBPS, cecal intubation and PDR improved from 40.4%, 60.5%, 47.6%, 69.8% and 32.3% in 2016 to 90.3%, 88.9%, 59.8%, 79.1% and 39.1%, respectively, in 2020. For CRC-cancer screening colonoscopy registration equaled outcome, PDR and ADR changed from 74.7% to 63.6% in 2016 to 66.3% and 53.8% in 2020, respectively.

CONCLUSIONS

The quality of endoscopy data registration has consistently improved over the years by using the Trans.IT database. This is most likely the result of feedback to performing endoscopists to review performance in real-time online and progressive awareness of quality of data registration.

Estimating oncologist variability in prescribing systemic cancer therapies to patients in the last 30 days of life

INTRODUCTION

Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation.

RESULTS

Patients' median age at the time of death was 74 years (interquartile range, 69-79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end-of-life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end-of-life cancer therapy (OR, 4.42; 95% CI, 4.00-4.89).

CONCLUSIONS

Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies.

Current oral care practices in an acute aged care setting: An Australian metropolitan hospital perspective

PURPOSE

To evaluate current oral care practices in an acute aged care hospital setting, and staff perceptions of the barriers and enablers to delivery of evidence-based oral care practices.

METHOD

A mixed method study comprised of retrospective file audit and cross-sectional survey was conducted within a single acute aged care unit. Medical records of patients aged ≥ 65 years admitted over a 6 month period were retrospectively audited. A clinician survey was used to explore barriers to and enablers of the delivery of oral care practices using the Capability, Opportunity, Motivation, Behaviour (COM-B) questionnaire. Result were analysed using descriptive statistics.

RESULT

Patient file audits (n = 206) found 13.6% (n = 28) of patients had oral care completed, despite 23% (n = 47) of patients being recommended by a speech language pathologist to receive oral care. Staff survey respondents (n = 31) reported they do not have the physical or social opportunities to provide oral care (i.e. adequate resources, time, and social support), however, they were motivated and reported they have the required knowledge and skills to provide oral care.

CONCLUSION

There is a need for implementation strategies to enable an interprofessional response to improve the delivery of evidence-based oral care practices and optimise patient outcomes.

Pervasiveness and clinical staff perceptions of HPV vaccination feedback

OBJECTIVES

This study describes the use of data-based feedback, such as human papillomavirus (HPV) vaccination rates, to advance HPV vaccination uptake in pediatric and family medicine clinics.

STUDY DESIGN

A survey of primary care clinical staff in the US who provided HPV vaccination to children aged 9 to 12 years (N = 2527; response rate, 57%).

METHODS

The primary outcome was a mutually exclusive categorical variable that described the type of quality metrics for which providers received feedback in the past year: HPV vaccine, other pediatric vaccinations, other quality metrics, or none. Secondary outcomes were provider perceptions of HPV vaccine feedback helpfulness and their comfort with colleagues seeing their HPV vaccination rates. Logistic models adjusted for clinical staff and clinic characteristics.

RESULTS

Only 36.2% (n = 916) of respondents received HPV feedback. Feedback on HPV vaccination rates was more likely in nonrural clinics (OR, 2.03; 95% CI, 1.38-2.99), clinics in systems of 5 or more (OR, 1.81; 95% CI, 1.38-2.36), and in clinics serving 50 or more children per week (OR, 3.08; 95% CI, 2.03-4.66). Hispanic, Latino, or Spanish (OR, 1.54; 95% CI, 1.00-2.36) and Black or African American clinical staff (OR, 2.12; 95% CI, 1.44-3.12) were more likely than White clinical staff to find HPV vaccine feedback helpful. Relative to pediatricians, family medicine clinical staff were less comfortable with colleagues seeing their HPV vaccination rates (OR, 0.70; 95% CI, 0.57-0.87).

CONCLUSIONS

Clinical staff seldom receive feedback about HPV vaccination in primary care.

Identifying Barriers and Implementation Strategies to Inform TBI Screening Adoption in Behavioral Healthcare Settings

OBJECTIVE

Identify barriers to the adoption of the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) in behavioral healthcare organizations and match these barriers to implementation strategies to inform future implementation efforts.

PARTICIPANTS

Twenty behavioral health providers.

DESIGN

Qualitative study involving individual, semi-structured interviews regarding barriers to adopting the OSU TBI-ID. Data were thematically analyzed around constructs from the Consolidated Framework for Implementation Research (CFIR). Results were matched to strategies using the Expert Recommendations for Implementing Change (CFIR/ERIC) matching tool.

RESULTS

Ten barriers were identified across 4 CFIR domains. Inner-Setting barriers were inadequate leadership engagement, priorities, resources, and organizational incentives. Individual-Characteristics barriers were insufficient knowledge about the connection between TBI and behavioral health and how to conduct the OSU TBI-ID with fidelity, low self-efficacy to conduct screening, and inadequate motivation and buy-in to conduct screening. Outer-Setting barriers were lack of state-level mandates and inadequate incentives to conduct screenings. The Process domain barrier was an insufficient engagement of key personnel. Strategy recommendations include: identify and prepare champions; alter incentive and allowance structures; inform local opinion leaders; build a coalition; access new funding; conduct local consensus discussions; involve executive boards; capture/share local knowledge; conduct educational meetings; assess for readiness and identify determinants; identify early adopters; fund and contract for the clinical innovation; create a learning collaborative; and conduct a local needs assessment.

CONCLUSIONS

This is the first study to examine barriers to adopting the OSU TBI-ID in real-world practice settings. Our results suggest that multilevel implementation strategies addressing mechanisms of change are necessary at the provider, organizational, and systems levels to overcome the complex barriers affecting TBI screening adoption and implementation. Future research is needed to test these strategies and their mechanisms of action on the adoption, implementation, and sustainment of TBI screening, as well as their effect on client-level outcomes.

Implementation of ERAS Protocols: In Theory and Practice

The enhanced recovery after surgery (ERAS) pathway is a perioperative care pathway intended to facilitate early recovery and minimize hospital stays among patients undergoing major surgery. Critical factors for successful ERAS implementation, which may vary depending on care processes, include a multidisciplinary team, organizational commitment to change, and a real-time system for compliance and outcome audits. As most clinicians and health organizations can attest, incorporating and implementing new evidence-based practice changes almost always involves overcoming systemic challenges and obstacles. The same holds true for ERAS programs. The main barriers to ERAS protocol implementation have been resistance to change, lack of time and resources, and inadequate communication and coordination among departments. According to evidence-based ERAS guidelines, the best way to efficiently implement all recommendations into practice is to discover. Implementation science aims to identify and address care gaps, support change in practice, and enhance healthcare quality. Implementation research should also build a robust and generalizable evidence base to inform implementation practice. Most implementation investigations focus on one of two approaches to achieving change. Implementation can progress through top-down or bottom-up processes depending on factors such as national policies, organizational properties, or the implementation culture of society, especially for health issues. Although the ERAS guidelines are based on evidence-based knowledge, only a limited number of health centers around the world have officially been able to implement them. The purpose of this review is to analyze the implementation of the ERAS pathways in theory and practice in Turkey, considering the absence of an ERAS-qualified center in Turkey.

Bridging the gap: a qualitative process evaluation from the perspectives of healthcare professionals of an audit-and-feedback-based intervention to improve transition to adult care for young people living with type 1 diabetes

BACKGROUND

The transition from pediatric to adult care is a vulnerable time for young people living with type 1 diabetes (T1D). Bridging the Gap (BTG) is an audit-and-feedback (AF) intervention aimed at improving both transitions-in-care processes and diabetes management in the year following transition. As part of BTG, we conducted a qualitative process evaluation to understand: (a) what was implemented and how; and (b) the contextual factors (micro-, meso- and macro-) that affected implementation, outcomes and study processes.

METHODS

Using qualitative descriptive methodology, interviews were conducted with 13 healthcare professionals (HCPs) delivering diabetes care to transitioning youth. Participants were asked about their experiences of BTG study processes and feedback tools, the quality improvement (QI) initiatives implemented at their site, and potential spread and scale. Interviews also explored the impacts of COVID-19 on transition care and study processes and results.

RESULTS

Five key themes were identified. Participants' reflections on the BTG study design indicated they appreciated its flexible, site-specific approach to QI, which they saw as crucial to the success of their initiatives. Engagement with feedback reports and other study resources provided comparative, site-specific data. Participants described the challenges posed by the COVID-19 pandemic and its impacts on patients, care provision and study implementation. Their site-specific QI initiatives resulted in changes to their transition practices. Finally, participants commented on how BTG and its processes fostered a community of practice (CoP) between sites, resulting in new opportunities to collaborate and share experiences.

CONCLUSIONS

BTG resulted in a CoP among practitioners delivering transition care to youth with T1D, which could be scaled up to promote a learning health system in pediatric diabetes care. Qualitative process evaluation is a useful tool for understanding how contextual factors affect the implementation and outcomes of complex QI interventions.

Strengthening crisis resilience in German primary care by using quality indicators: findings of a process evaluation in the RESILARE project

BACKGROUND

In recent years, health systems worldwide have been confronted with several crises such as natural disasters or the COVID-19 pandemic, that affected lives and health of many people. In light of waves of infections and heat, climate change is considered to be the biggest health threat of the 21st century. Strengthening individual and organizational crisis resilience in healthcare settings thus becomes a crucial factor in maintaining care quality and protecting vulnerable patients during such crises. The RESILARE project therefore aimed to develop and evaluate quality indicators that support primary care practices in preparing for and adapting to crisis-related challenges.

METHODS

In a three-phased process, indicator development was based on systematic literature research and qualitative data, a two-stage expert panel process, and pilot testing in a maximum of n = 35 ambulatory practices during an outreach visit. Practice-individual indicator-related status and benchmarking information were provided via feedback reports to complete the audit and feedback program. A mixed-methods process evaluation used semistructured interviews with participating General practitioners and nonphysician health professionals to explore support and challenges for the implementation of the derived set of quality indicators. Two online surveys were conducted to evaluate all indicators and the two-part feedback report. Qualitative data were analyzed inductively using a thematic analysis approach. Survey data were analyzed descriptively.

RESULTS

A total of n = 32 indicators covered four domains: (1) individual resilience, (2) crisis prevention, (3) organizational resilience, and (4) climate resilience. N = 34 practices participated in the piloting and the process evaluation. Participants generally attributed a high relevance to the domains, and considered the indicator set suitable for implementation into existing quality management systems. Planning and implementation of measures that strengthen crisis resilience in practices were triggered or intensified by piloting the indicators and by the two-part feedback report. The identified challenges involved the volume of indicators and practice-individual implementation of renewable energy sources on rented premises. Participants expressed their desire for peer exchange regarding proven concepts for crisis resilience.

Association between delayed outbreak identification and SARS-CoV-2 infection and mortality among long-term care home residents, Ontario, Canada, March to November 2020: a cohort study

BackgroundLate outbreak identification is a common risk factor mentioned in case reports of large respiratory infection outbreaks in long-term care (LTC) homes.AimTo systematically measure the association between late SARS-CoV-2 outbreak identification and secondary SARS-CoV-2 infection and mortality in residents of LTC homes.MethodsWe studied SARS-CoV-2 outbreaks across LTC homes in Ontario, Canada from March to November 2020, before the COVID-19 vaccine rollout. Our exposure (late outbreak identification) was based on cumulative infection pressure (the number of infectious resident-days) on the outbreak identification date (early: ≤ 2 infectious resident-days, late: ≥ 3 infectious resident-days), where the infectious window was -2 to +8 days around onset. Our outcome consisted of 30-day incidence of secondary infection and mortality, based on the proportion of at-risk residents with a laboratory-confirmed SARS-CoV-2 infection with onset within 30 days of the outbreak identification date.ResultsWe identified 632 SARS-CoV-2 outbreaks across 623 LTC homes. Of these, 36.4% (230/632) outbreaks were identified late. Outbreaks identified late had more secondary infections (10.3%; 4,437/42,953) and higher mortality (3.2%; 1,374/42,953) compared with outbreaks identified early (infections: 3.3%; 2,015/61,714; p < 0.001, mortality: 0.9%; 579/61,714; p < 0.001). After adjustment for 12 LTC home covariates, the incidence of secondary infections in outbreaks identified late was 2.90-fold larger than that of outbreaks identified early (OR: 2.90; 95% CI: 2.04-4.13).ConclusionsThe timeliness of outbreak identification could be used to predict the trajectory of an outbreak, plan outbreak measures and retrospectively provide feedback for quality improvement, with the objective of reducing the impacts of respiratory infections in LTC home residents.

Establishing Quality Indicators and Implementation Priorities for Post-Stroke Aphasia Services Through End-User Involvement

BACKGROUND

Currently, there are no agreed quality standards for post-stroke aphasia services. Therefore, it is unknown if care reflects best practices or meets the expectations of people living with aphasia. We aimed to (1) shortlist, (2) operationalise and (3) prioritise best practice recommendations for post-stroke aphasia care.

METHODS

Three phases of research were conducted. In Phase 1, recommendations with strong evidence and/or known to be important to people with lived experience of aphasia were identified. People with lived experience and health professionals rated the importance of each recommendation through a two-round e-Delphi exercise. Recommendations were then ranked for importance and feasibility and analysed using a graph theory-based voting system. In Phase 2, shortlisted recommendations from Phase 1 were converted into quality indicators for appraisal and voting in consensus meetings. In Phase 3, priorities for implementation were established by people with lived experience and health professionals following discussion and anonymous voting.

FINDINGS

In Phase 1, 23 best practice recommendations were identified and rated by people with lived experience (n = 26) and health professionals (n = 81). Ten recommendations were shortlisted. In Phase 2, people with lived experience (n = 4) and health professionals (n = 17) reached a consensus on 11 quality indicators, relating to assessment (n = 2), information provision (n = 3), communication partner training (n = 3), goal setting (n = 1), person and family-centred care (n = 1) and provision of treatment (n = 1). In Phase 3, people with lived experience (n = 5) and health professionals (n = 7) identified three implementation priorities: assessment of aphasia, provision of aphasia-friendly information and provision of therapy.

INTERPRETATION

Our 11 quality indicators and 3 implementation priorities are the first step to enabling systematic, efficient and person-centred measurement and quality improvement in post-stroke aphasia services. Quality indicators will be embedded in routine data collection systems, and strategies will be developed to address implementation priorities.

PATIENT AND PUBLIC CONTRIBUTION

Protocol development was informed by our previous research, which explored the perspectives of 23 people living with aphasia about best practice aphasia services. Individuals with lived experience of aphasia participated as expert panel members in our three consensus meetings. We received support from consumer advisory networks associated with the Centre for Research Excellence in Aphasia Rehabilitation and Recovery and the Queensland Aphasia Research Centre.

Development of a behaviour change intervention to increase the delivery of upper limb constraint-induced movement therapy programs to people with stroke and traumatic brain injury

PURPOSE

Constraint-induced movement therapy (CIMT) is a recommended intervention for arm recovery after acquired brain injury but is underutilised in practice. The purpose of this study is to describe the development of a behaviour change intervention targeted at therapists, to increase delivery of CIMT.

METHODS

A theoretically-informed approach for designing behaviour change interventions was used including identification of which behaviours needed to change (Step 1), barriers and enablers that needed to be addressed (Step 2), and intervention components to target those barriers and enablers (Step 3). Data collection methods included file audits and therapist interviews. Quantitative data (file audits) were analysed using descriptive statistics. Qualitative data analysis (interviews) was informed by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel.

RESULTS

Fifty two occupational therapists, physiotherapists and allied health assistants participated in focus groups (n = 7) or individual interviews (n = 6). Key barriers (n = 20) and enablers (n = 10) were identified across 11 domains of the TDF and perceived to influence CIMT implementation. The subsequent behaviour change intervention included training workshops, nominated team champions, community of practice meetings, three-monthly file audit feedback cycles, poster reminders and drop-in support during CIMT.

CONCLUSION

This study describes the development of a behaviour change intervention to increase CIMT delivery by clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617001147370.

Practice visitations in primary care to improve performance of cardiovascular risk management: an observational study

BACKGROUND

Despite programmatic protocolised care and structured support, considerable variation is observed in completeness of registration and achieving targets of cardiovascular risk management (CVRM) between individual GPs in the Netherlands.

AIM

To determine whether completeness of registration and achieved targets of cardiovascular risk factors improves with practice visitation.

DESIGN & SETTING

Observational study utilising the care group's database (2016-2019), comparing changes in registration and achieved targets in non-visited practices and visited practices.

METHOD

We compared completeness scores of registration and scores of targets achieved before visitation and 1 year after visitation. Data were analysed on patient level and GP level. Separate analyses were performed among GPs who were ranked in the lower 25% of score distributions.

RESULTS

We observed no clinically relevant improvements in completeness of registration and targets achieved in 2017, 2018, and 2019 that could be attributed to visitations in the previous year, both on individual patient level and on aggregated level per general practice. In practices ranked in the lower 25% of the distribution, improvements over time were clinically relevant and larger than the overall changes. Yet, these findings were irrespective of the number of practice visitations.

CONCLUSION

Practice visitations in our setting did not seem to lead to improvements in practice performance, nor in completeness of registration of risk factors or in reaching predefined target goals for cardiovascular risk factors.

Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis

BACKGROUND

Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes.

METHODS

A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE.

RESULTS

Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses' attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes.

CONCLUSIONS

Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes.

TRIAL REGISTRATION

PROSPERO CRD42019130446.

Emergency clinicians' use of adult and paediatric sepsis pathways: An implementation redesign using the behaviour change wheel

AIMS

To identify facilitators and barriers and tailor implementation strategies to optimize emergency clinician's use of adult and paediatric sepsis pathways.

DESIGN

A qualitative descriptive study using focus group methodology.

METHODS

Twenty-two emergency nurses and ten emergency medical officers from four Australian EDs participated in eight virtual focus groups. Participants were asked about their experiences using the New South Wales Clinical Excellence Commission adult and paediatric sepsis pathways using a semi-structured interview template. Facilitators and barriers to use of the sepsis pathways were categorized using the Theoretical Domains Framework. Tailored interventions were selected to address facilitators and barriers, and a re-implementation plan was devised guided by the Behaviour Change Wheel.

RESULTS

Thirty-two facilitators and 58 barriers were identified corresponding to 11 Theoretical Domains Framework domains. Tailored strategies were selected to optimize emergency clinicians' use of the sepsis pathways including refinement of existing education and training programmes, modifications to the electronic medical record system, introduction of an audit and feedback system, staffing strategies and additional resources.

CONCLUSION

The implementation of sepsis pathways in the Emergency Department setting is complex, impacted by a multitude of factors requiring tailored strategies to address facilitators and barriers and optimize uptake.

IMPLICATIONS FOR PATIENT CARE

This study presents a theory-informed systematic approach to successfully implement and embed adult and paediatric sepsis pathways into clinical practice in the Emergency Department.

IMPACT

Optimizing uptake of sepsis pathways has the potential to improve sepsis recognition and management, subsequently improving the outcome of patients with sepsis.

REPORTING METHOD

The Consolidated Criteria for REporting Qualitative research guided the preparation of this report.

PATIENT OR PUBLIC CONTRIBUTION

Nil.

Variational Bayes machine learning for risk adjustment of general outcome indicators with examples in urology

Risk adjustment is often necessary for outcome quality indicators (QIs) to provide fair and accurate feedback to healthcare professionals. However, traditional risk adjustment models are generally oversimplified and not equipped to disentangle complex factors influencing outcomes that are out of a healthcare professional's control. We present VIRGO, a novel variational Bayes model trained on routinely collected, large administrative datasets to risk-adjust outcome QIs. VIRGO uses detailed demographics, diagnosis, and procedure codes to provide individualized risk adjustment and explanations on patient factors affecting outcomes. VIRGO achieves state-of-the-art on external datasets and features capabilities of uncertainty expression, explainable features, and counterfactual analysis capabilities. VIRGO facilitates risk adjustment by explaining how patient factors led to adverse outcomes and expresses the uncertainty of each prediction, allowing healthcare professionals to not only explore patient factors with unexplained variance that are associated with worse outcomes but also reflect on the quality of their clinical practice.

Prevalence, predictors and outcomes of self-reported feedback for EMS professionals: a mixed-methods diary study

BACKGROUND

Providing feedback to healthcare professionals and organisations on performance or patient outcomes may improve care quality and professional development, particularly in Emergency Medical Services (EMS) where professionals make autonomous, complex decisions and current feedback provision is limited. This study aimed to determine the content and outcomes of feedback in EMS by measuring feedback prevalence, identifying predictors of receiving feedback, categorising feedback outcomes and determining predictors of feedback efficacy.

METHODS

An observational mixed-methods study was used. EMS professionals delivering face-to-face patient care in the United Kingdom's National Health Service completed a baseline survey and diary entries between March-August 2022. Diary entries were event-contingent and collected when a participant identified they had received feedback. Self-reported data were collected on feedback frequency, environment, characteristics and outcomes. Feedback environment was measured using the Feedback Environment Scale. Feedback outcomes were categorised using hierarchical cluster analysis. Multilevel logistic regression was used to assess which variables predicted feedback receipt and efficacy. Qualitative data were analysed using content analysis.

RESULTS

299 participants completed baseline surveys and 105 submitted 538 diary entries. 215 (71.9%) participants had received feedback in the last 30 days, with patient outcome feedback the most frequent (n = 149, 42.8%). Feedback format was predominantly verbal (n = 157, 73.0%) and informal (n = 189, 80.4%). Significant predictors for receiving feedback were a paramedic role (aOR 3.04 [1.14, 8.00]), a workplace with a positive feedback-seeking culture (aOR 1.07 [1.04, 1.10]) and white ethnicity (aOR 5.68 [1.01, 29.73]). Feedback outcomes included: personal wellbeing (closure, confidence and job satisfaction), professional development (clinical practice and knowledge) and service outcomes (patient care and patient safety). Feedback-seeking behaviour and higher scores on the Feedback Environment Scale were statistically significant predictors of feedback efficacy. Solicited feedback improved wellbeing (aOR 3.35 [1.68, 6.60]) and professional development (aOR 2.58 [1.10, 5.56]) more than unsolicited feedback.

CONCLUSION

Feedback for EMS professionals was perceived to improve personal wellbeing, professional development and service outcomes. EMS workplaces need to develop a culture that encourages feedback-seeking to strengthen the impact of feedback for EMS professionals on clinical decision-making and staff wellbeing.

Factors Influencing Implementation of the Commission on Cancer's Breast Synoptic Operative Report (Alliance A20_Pilot9)

BACKGROUND

The technical aspects of cancer surgery have a significant impact on patient outcomes. To monitor surgical quality, in 2020, the Commission on Cancer (CoC) revised its accreditation standards for cancer surgery and introduced the synoptic operative reports (SORs). The standardization of SORs holds promise, but successful implementation requires strategies to address key implementation barriers. This study aimed to identify the barriers and facilitators to implementing breast SOR within diverse CoC-accredited programs.

METHODS

In-depth semi-structured interviews were conducted with 31 health care professionals across diverse CoC-accredited sites. The study used two comprehensive implementation frameworks to guide data collection and analysis.

RESULTS

Successful SOR implementation was impeded by disrupted workflows, surgeon resistance to change, low prioritization of resources, and poor flow of information despite CoC's positive reputation. Participants often lacked understanding of the requirements and timeline for breast SOR and were heavily influenced by prior experiences with templates and SOR champion relationships. The perceived lack of monetary benefits (to obtaining CoC accreditation) together with the significant information technology (IT) resource requirements tempered some of the enthusiasm. Additionally, resource constraints and the redirection of personnel during the COVID-19 pandemic were noted as hurdles.

CONCLUSIONS

Surgeon behavior and workflow change, IT and personnel resources, and communication and networking strategies influenced SOR implementation. During early implementation and the implementation planning phase, the primary focus was on achieving buy-in and initiating successful roll-out rather than effective use or sustainment. These findings have implications for enhancing standardization of surgical cancer care and guidance of future strategies to optimize implementation of CoC accreditation standards.

Development of a Behavior-Change Intervention toward Benzodiazepine Deprescribing in Older Adults Living in Nursing Homes

OBJECTIVE

We aimed to develop a context-specific intervention toward benzodiazepine deprescribing in nursing homes (NHs), with insights from behavior-change theories and involvement of stakeholders.

DESIGN

Selection of behavior change techniques (BCTs), through online survey and group discussion, followed by operationalization of these BCTs into intervention components.

SETTING AND PARTICIPANTS

The intervention was developed for Belgian NHs, involving various stakeholders: health care professionals (HCPs), NH administrators, and policy makers.

METHODS

Using the Theory and Techniques Tool, we preselected the BCTs linked to one of the 9 Theoretical Domain Framework domains identified as being the main barriers for benzodiazepine deprescribing in Belgian NHs. These were then presented to stakeholders. Based on the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Ethics) criteria, participants ranked BCTs through an online survey, and then performed final selection during a group discussion. Selected BCTs were operationalized into intervention components, with specific contents and methods of delivery validated by stakeholders.

RESULTS

Thirty-seven potential BCTs were identified. Eighteen stakeholders participated in the survey, and 7 in the group discussion. This led to the final inclusion of 9 BCTs: instruction on how to perform the behavior, information about health consequences, pros and cons, problem solving, goal setting (behavior), social comparison, restructuring physical environment, restructuring social environment, and graded tasks. These BCTs were operationalized into a 6-component intervention: process and goal setting, HCP education, physical environment adaptations, audit and feedback, NH residents' and relatives' increased awareness, and multidisciplinary work.

CONCLUSION AND IMPLICATIONS

Use of a theory-based approach toward intervention development has the potential to improve the probability of its feasibility and effectiveness in tackling barriers to benzodiazepine deprescribing. By doing so, we have developed a multifaceted approach with actions taken at the patient, HCP, and NH levels. Our novel 6-component intervention will be evaluated in a pilot cluster-randomized controlled trial to assess its feasibility.

Disparity in Guideline-Based Antidiabetic Drugs Prescribing for Type 2 Diabetes Patients in Primary Healthcare Facilities Across China, 2017-2019

PURPOSE

The purpose of this study is to evaluate the pattern, appropriateness, and cost of antidiabetic drugs prescribed for patients with Type 2 diabetes at primary healthcare facilities (PHFs) in China.

METHODS

We collected outpatient-visit prescriptions from 363 PHFs in 31 cities covering eastern, central, and western regions of China. The visits of adult patients with Type 2 diabetes diagnosis were collected and classified the antidiabetic medication pattern of each patient use as recommended or non-recommended according to Chinese guidelines. We then calculated the proportion of guideline-recommended patterns and the average monthly cost for each pattern, overall and by region.

RESULTS

Of 33 519 prescriptions for Type 2 diabetes, most (73.9%) were for guideline-recommended antidiabetic treatments. The proportion of guideline-recommended prescriptions varied by region (eastern [75.9%], central [87.5%], and western [59.7%]). Metformin monotherapy was the most common guideline-recommended treatment in all three regions (eastern [20.1%], central [28.0%], and western [24.6%]). The most common non-guideline-recommended treatments were monotherapy of insulin (eastern [16.5%], central [5.1%], and western [25.7%]) and traditional Chinese antidiabetic medicines (eastern [5.6%], central [5.7%], and western [11.1%]). The average monthly costs were lower for guideline-recommended treatments compared to non-recommended treatments in all regions (eastern [13.6 ± 15.4 USD vs. 28.1 ± 22.0 USD], central [9.8 ± 10.9 USD vs. 28.7 ± 19.4 USD], and western [17.9 ± 21.4 USD vs. 30.3 ± 23.6 USD]).

CONCLUSIONS

The majority of patients with Type 2 diabetes received guideline-recommended antidiabetic medications at PHFs in China, with only half of the prescriptions containing guideline-recommended metformin. Utilization of guideline-recommended therapies differed across regions. Tailored interventions to promote evidence-based antidiabetic prescribing are urgently needed, especially in the undeveloped western region.

Comparative performance of intensive care mortality prediction models based on manually curated versus automatically extracted electronic health record data

INTRODUCTION

Benchmarking intensive care units for audit and feedback is frequently based on comparing actual mortality versus predicted mortality. Traditionally, mortality prediction models rely on a limited number of input variables and significant manual data entry and curation. Using automatically extracted electronic health record data may be a promising alternative. However, adequate data on comparative performance between these approaches is currently lacking.

METHODS

The AmsterdamUMCdb intensive care database was used to construct a baseline APACHE IV in-hospital mortality model based on data typically available through manual data curation. Subsequently, new in-hospital mortality models were systematically developed and evaluated. New models differed with respect to the extent of automatic variable extraction, classification method, recalibration usage and the size of collection window.

RESULTS

A total of 13 models were developed based on data from 5,077 admissions divided into a train (80%) and test (20%) cohort. Adding variables or extending collection windows only marginally improved discrimination and calibration. An XGBoost model using only automatically extracted variables, and therefore no acute or chronic diagnoses, was the best performing automated model with an AUC of 0.89 and a Brier score of 0.10.

DISCUSSION

Performance of intensive care mortality prediction models based on manually curated versus automatically extracted electronic health record data is similar. Importantly, our results suggest that variables typically requiring manual curation, such as diagnosis at admission and comorbidities, may not be necessary for accurate mortality prediction. These proof-of-concept results require replication using multi-centre data.

Implementing Enhanced Recovery After Surgery for hysterectomy in a hospital network with audit and feedback: A stepped-wedge cluster randomised trial

OBJECTIVE

To evaluate the effectiveness of implementing the Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing elective hysterectomy in a network of regional hospitals, supported by an intensive audit-and-feedback (A&F) approach.

DESIGN

A multi-centre, stepped-wedge cluster randomised trial (ClinicalTrials.gov NCT04063072).

SETTING

Gynaecological units in the Piemonte region, Italy.

POPULATION

Patients undergoing elective hysterectomy, either for cancer or for benign conditions.

METHODS

Twenty-three units (clusters), stratified by surgical volume, were randomised into four sequences. At baseline (first 3 months), standard care was continued in all units. Subsequently, the four sequences implemented the ERAS protocol successively every 3 months, after specific training. By the end of the study, each unit had a period in which standard care was maintained (control) and a period in which the protocol, supported by feedback, was applied (experimental).

MAIN OUTCOME MEASURES

Length of hospital stay (LOS), without outliers (>98th percentile).

RESULTS

Between September 2019 and May 2021, 2086 patients were included in the main analysis with an intention-to-treat approach: 1104 (53%) in the control period and 982 (47%) in the ERAS period. Compliance with the ERAS protocol increased from 60% in the control period to 76% in the experimental period, with an adjusted absolute difference of +13.3% (95% CI 11.6% to 15.0%). LOS, moving from 3.5 to 3.2 days, did not show a significant reduction (-0.12 days; 95% CI -0.30 to 0.07 days). No difference was observed in the occurrence of complications.

CONCLUSIONS

Implementation of the ERAS protocol for hysterectomy at the regional level, supported by an A&F approach, resulted in a substantial improvement in compliance, but without meaningful effects on LOS and complications. This study confirms the effectiveness of A&F in promoting important innovations in an entire hospital network and suggests the need of a higher compliance with the ERAS protocol to obtain valuable improvements in clinical outcomes.

Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization

BACKGROUND

Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada.

METHODS

We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes.

DISCUSSION

The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work.

TRIAL REGISTRATION

This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.

How can strategies based on performance measurement and feedback support changes in nursing practice? A theoretical reflection drawing on Habermas' social perspective

Strategies based on performance measurement and feedback are commonly used to support quality improvement among nurses. These strategies require practice change, which, for nurses, rely to a large extent on their capacity to coordinate with each other effectively. However, the levers for coordinated action are difficult to mobilize. This discussion paper offers a theoretical reflection on the challenges related to coordinating nurses' actions in the context of practice changes initiated by performance measurement and feedback strategies. We explore how Jürgen Habermas' theory of Communicative Action may shed light on the issues underlying nurses' collective actions and self-determination in practice change and the implications for the design of strategies based on performance measurement and feedback. Based on this theory, we propose differences between communicative and functional coordination according to the nature of the actions and the purposes involved. The domains of action underlying these coordination processes, which Habermas referred to as the lifeworld and the system, are then used to draw a parallel with aspects of nursing practice. Further exploration of these concepts allows us to consider the tensions between the demands of the system and the self-determination of nurses within their practice.

Utilizing the open-source programming language Python to create interactive Quality Assurance dashboards for diagnostic and screening performance in Cytology

INTRODUCTION

Effective feedback on cytology performance relies on navigating complex laboratory information system data, which is prone to errors and lacks flexibility. As a comprehensive solution, we used the Python programming language to create a dashboard application for screening and diagnostic quality metrics.

MATERIALS AND METHODS

Data from the 5-year period (2018-2022) were accessed. Versatile open-source Python libraries (user developed program code packages) were used from the first step of LIS data cleaning through the creation of the application. To evaluate performance, we selected 3 gynecologic metrics: the ASC/LSIL ratio, the ASC-US/ASC-H ratio, and the proportion of cytologic abnormalities in comparison to the total number of cases (abnormal rate). We also evaluated the referral rate of cytologists/cytotechnologists (CTs) and the ratio of thyroid AUS interpretations by cytopathologists (CPs). These were formed into colored graphs that showcase individual results in established, color-coded laboratory "goal," "borderline," and "attention" zones based on published reference benchmarks. A representation of the results distribution for the entire laboratory was also developed.

RESULTS

We successfully created a web-based test application that presents interactive dashboards with different interfaces for the CT, CP, and laboratory management (https://drkvcsstvn-dashboards.hf.space/app). The user can choose to view the desired quality metric, year, and the anonymized CT or CP, with an additional automatically generated written report of results.

CONCLUSIONS

Python programming proved to be an effective toolkit to ensure high-level data processing in a modular and reproducible way to create a personalized, laboratory specific cytology dashboard.

Evaluating a novel model of hepatitis B care, Hep B PAST, in the Northern Territory of Australia: results from a prospective, population-based study

Background

The Northern Territory (NT) has the highest prevalence of chronic hepatitis B (CHB) in Australia. The Hep B PAST program aims to improve health outcomes for people living with CHB.

Methods

This mixed methods study involves First Nations peoples living in the NT. We used participatory action research principles across three steps: 1. Foundation step: establishing hepatitis B virus (HBV) status and linkage to care; 2. Capacity building: training the health workforce; 3. Supported transition to primary healthcare: implementation of the "Hub and Spoke" model and in-language resources. Analysis occurred at three time points: 1. Pre-Hep B PAST (2018); 2. Foundation step (2020); and 3. Completion of Hep B PAST (2023). Evaluation focuses on four key indicators, the number of people: 1) with documented HBV status; 2) diagnosed with CHB; 3) receiving care; and 4) receiving treatment.

Findings

Hep B PAST (2018-23) reached 40,555 people. HBV status was documented in 11% (1192/10,853), 79.2% (26,075/32,915) and 90.8% (28,675/31,588) of people at pre-Hep B PAST, foundation step, and completion respectively. An estimated 99.9% (821/822) of people were diagnosed, 86.3% (709/822) engaged in care, and 24.1% (198/822) on antiviral treatment at completion. CHB prevalence in the study population is 2.6%, decreasing from 6.1% to 0.4% in the pre- and post-vaccination cohorts.

Interpretation

Hep B PAST is an effective model of care. Partner health services are exceeding elimination targets. This model could enable other countries to enhance the cascade of care and work towards eliminating HBV.

Funding

National Health and Medical Research Council.

How to Design Effective Audit and Feedback Interventions With Nurses: A Set of Hypotheses Based on Qualitative and Quantitative Evidence

OBJECTIVE

To propose practical hypotheses on audit and feedback that support the effectiveness with nurses.

BACKGROUND

Audit and feedback interventions have been mainly studied with physicians; however, the processes have been practiced by nurses for years. Nurses' response may differ from that of physicians and other healthcare disciplines because of their roles, power, and the configuration of nursing activities.

METHODS

A comparative analysis of the Clinical Performance Feedback Intervention Theory was conducted using nursing-specific empirical data from: 1) a mixed-methods systematic review and 2) a pilot study of audit and feedback with a team of primary care nurses.

RESULTS

Researchers hypothesize that audit and feedback interventions are more effective when: 1) feedback emphasizes how it relates to the relational aspect of nursing; 2) indicators are measured and reported at team level; and 3) feedback is provided in a way that highlights benefits to nurses' practice, such as the potential to reduce workload.

CONCLUSION

These proposed hypotheses provide concrete guidance to researchers and managers for an effective use of audit and feedback as a quality improvement strategy with nurses.