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Fourré A, Fierens A, Michielsen J, Ris L, Dierick F, Roussel N. An interactive e-learning module to promote bio-psycho-social management of low back pain in healthcare professionals: a pilot study. J Man Manip Ther 2021; 30:105-115. [PMID: 34678129 DOI: 10.1080/10669817.2021.1988397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Introduction: Low back pain (LBP) is ranked as the first musculoskeletal disorder considering years lived with disability worldwide. Despite numerous guidelines promoting a bio-psycho-social (BPS) approach in the management of patients with LBP, many health care professionals (HCPs) still manage LBP patients mainly from a biomedical point of view. Objective: The purpose of this pilot study was to evaluate the feasibility of implementing an interactive e-learning module on the management of LBP in HCPs. Methods: In total 22 HCPs evaluated the feasibility of the e-learning module with a questionnaire and open questions. Participants filled in the Back Pain Attitude Questionnaire (Back-PAQ) before and after completing the module to evaluate their attitudes and beliefs about LBP. Results: The module was structured and easy to complete (91%) and met the expectations of the participants (86%). A majority agreed that the module improved their knowledge (69%). Some participants (77%) identified specific topics that might be discussed in more detail in the module. HCPs knowledge, beliefs and attitudes about LBP significantly improved following module completion (t = -7.63, P < .001) with a very large effect size (ds = -1.63). Conclusion: The module seems promising to change knowledge, attitudes and beliefs of the participants. There is an urgent need to develop and investigate the effect of educational interventions to favor best practice in LBP management and this type of e-learning support could promote the transition from a biomedical to a bio-psycho-social management of LBP in HCPs.
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Affiliation(s)
- Antoine Fourré
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (Movant), University of Antwerp, Belgium
| | | | - Jef Michielsen
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (Movant), University of Antwerp, Belgium.,Orthopaedic Department, University Hospital, Antwerp, Belgium
| | - Laurence Ris
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium
| | - Frédéric Dierick
- Laboratoire d'Analyse du Mouvement et de la Posture, Centre National De Rééducation Fonctionnelle Et De Réadaptation - Rehazenter, Luxembourg, Luxembourg.,CeREF, Haute Ecole Louvain En Hainaut, Mons, Belgium
| | - Nathalie Roussel
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (Movant), University of Antwerp, Belgium
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Mdoe P, Mills TA, Chasweka R, Nsemwa L, Petross C, Laisser R, Chimwaza A, Lavender T. Lay and healthcare providers' experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry. BMJ Open 2021; 11:e046248. [PMID: 34588235 PMCID: PMC8483042 DOI: 10.1136/bmjopen-2020-046248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Disrespectful care, which remains prevalent in low and middle-income countries (LMICs), acts as a barrier to women accessing skilled birth attendance, compromising care when services are available. Building on what was positive in facilities, we aimed to explore lay and healthcare providers' experience of respectful care to inform future interventions. SETTING Five maternity facilities in Mwanza Tanzania and Lilongwe Malawi. PARTICIPANTS 94 participants in Malawi (N=46) and Tanzania (N=48) including 24 women birthing live baby within the previous 12 months; 22 family members and 48 healthcare providers who regularly provided maternity care in the included facilities DESIGN: The study was guided by Appreciative Inquiry (AI). Semistructured, one-to-one interviews were conducted between January and December 2019. Interviews were audio-recorded, translated where necessary, transcribed verbatim, and analysed using the framework approach. RESULTS Four main themes describing participants positive experience and their vision of respectful care were identified: (1) empathic healthcare provider-woman interactions including friendly welcome and courteous language, well-timed appropriate care and information sharing, (2) an enabling environment, characterised by improvement of physical environment, the use of screens, curtains and wall partitions for privacy, availability of equipment and provision of incentives to staff, (3) supportive leadership demonstrated by the commitment of the government and facility leaders to provision of respectful care, ensuring availability of guidelines and policies, supportive supervision, reflective discussion and paying staff salaries timely, (4) providers' attitudes and behaviours characterised by professional values through readiness, compassionate communication and commitment. CONCLUSION The positive experiences of service users, families and healthcare providers provided insight into key drivers of respectful care in facilities in Tanzania and Malawi. Interventions targeting improved environment and privacy, healthcare provider communication and developing positive leadership structures in facilities could provide the basis for sustained improvement in respectful and dignified maternal and newborn care in LMICs.
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Affiliation(s)
- Paschal Mdoe
- Obstetrics and Gynecology, Haydom Lutheran Hospital, Mbulu, Tanzania
- Division of Nursing, Midwifery and Social work, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Tracey A Mills
- Department of International Public Heath, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Robert Chasweka
- Department of Nursing and Midwifery, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
| | - Livuka Nsemwa
- Department of Nursing and Midwifery, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Chisomo Petross
- Department of Nursing and Midwifery, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
| | - Rose Laisser
- Department of Nursing and Midwifery, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Angela Chimwaza
- Department of Nursing and Midwifery, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
| | - Tina Lavender
- Department of International Public Heath, Liverpool School of Tropical Medicine, Liverpool, UK
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Fernandez Turienzo C, Rayment-Jones H, Roe Y, Silverio SA, Coxon K, Shennan AH, Sandall J. A realist review to explore how midwifery continuity of care may influence preterm birth in pregnant women. Birth 2021; 48:375-388. [PMID: 33749001 DOI: 10.1111/birt.12547] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Midwifery continuity of care models are the only health system intervention associated with both a reduction in preterm birth (PTB) and an improvement in perinatal survival; however, questions remain about the mechanisms by which such positive outcomes are achieved. We aimed to uncover theories of change by which we can postulate how and why continuity of midwifery care models might affect PTB. METHODS We followed Pawson's guidance for conducting a realist review and performed a comprehensive search to identify existing literature exploring the impact of continuity models on PTB in all pregnant women. A realist methodology was used to uncover the context (C), mechanisms (M), and outcomes (O) and to develop a group of CMO configurations to illuminate middle-range theories. RESULTS Eleven papers were included from a wide variety of settings in the United Kingdom, Australia, and the United States. The majority of study participants had low socioeconomic status or social risk factors and received diverse models of midwifery continuity of care. Three themes-woman-midwife partnership, maternity pathways and processes, and system resources-encompassed ten CMO configurations. Building relationships, trust, confidence, and advocacy resulted in women feeling safer, less stressed, and more secure and respected, and encouraged them to access and engage in antenatal care with more opportunities for early prevention and diagnosis of complications, which facilitated effective management when compliance to guidelines was ensured. Organizational infrastructure, innovative partnerships, and robust community systems are crucial to overcome barriers, address women's complex needs, ensure quality of care, and reduce PTB risk. CONCLUSIONS Pregnant women living in different contexts in the United Kingdom, Australia, and the United States at low and mixed risk of complications and with low socioeconomic status or social risk factors experienced continuity models in similar ways, and similar underlying mechanisms may have influenced PTB outcomes. Further research is required to understand how continuity models may influence behavioral change, physiological stress levels, ethnic disparities in PTB and care coordination, and navigation of health services.
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Affiliation(s)
| | - Hannah Rayment-Jones
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Yvette Roe
- Molly Wardaguga Research Centre, College of Nursing and Midwifery, Charles Darwin University, Brisbane, Qld, Australia
| | - Sergio A Silverio
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Kirstie Coxon
- Department of Midwifery, Kingston University and St. George's, University of London, London, UK
| | - Andrew H Shennan
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jane Sandall
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, UK
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Curtis HJ, Bacon S, Croker R, Walker AJ, Perera R, Hallsworth M, Harper H, Mahtani KR, Heneghan C, Goldacre B. Evaluating the impact of a very low-cost intervention to increase practices' engagement with data and change prescribing behaviour: a randomized trial in English primary care. Fam Pract 2021; 38:373-380. [PMID: 33783497 DOI: 10.1093/fampra/cmaa128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Unsolicited feedback can solicit changes in prescribing. OBJECTIVES Determine whether a low-cost intervention increases clinicians' engagement with data, and changes prescribing; with or without behavioural science techniques. METHODS Randomized trial (ISRCTN86418238). The highest prescribing practices in England for broad-spectrum antibiotics were allocated to: feedback with behavioural impact optimization; plain feedback; or no intervention. Feedback was sent monthly for 3 months by letter, fax and email. Each included a link to a prescribing dashboard. The primary outcomes were dashboard usage and change in prescribing. RESULTS A total of 1401 practices were randomized: 356 behavioural optimization, 347 plain feedback, and 698 control. For the primary engagement outcome, more intervention practices had their dashboards viewed compared with controls [65.7% versus 55.9%; RD 9.8%, 95% confidence intervals (CIs): 4.76% to 14.9%, P < 0.001]. More plain feedback practices had their dashboard viewed than behavioural feedback practices (69.1% versus 62.4%); but not meeting the P < 0.05 threshold (6.8%, 95% CI: -0.19% to 13.8%, P = 0.069). For the primary prescribing outcome, intervention practices possibly reduced broad-spectrum prescribing to a greater extent than controls (1.42% versus 1.12%); but again not meeting the P < 0.05 threshold (coefficient -0.31%, CI: -0.7% to 0.1%, P = 0.104). The behavioural impact group reduced broad-spectrum prescribing to a greater extent than plain feedback practices (1.63% versus 1.20%; coefficient 0.41%, CI: 0.007% to 0.8%, P = 0.046). No harms were detected. CONCLUSIONS Unsolicited feedback increased practices' engagement with data, with possible slightly reduced antibiotic prescribing (P = 0.104). Behavioural science techniques gave greater prescribing effects. The modest effects on prescribing may reflect saturation from similar initiatives on antibiotic prescribing. CLINICAL TRIAL REGISTRATION ISRCTN86418238.
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Affiliation(s)
- Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Bogers SJ, Schim van der Loeff MF, van Dijk N, Groen K, Groot Bruinderink ML, de Bree GJ, Reiss P, Geerlings SE, van Bergen JEAM. Rationale, design and initial results of an educational intervention to improve provider-initiated HIV testing in primary care. Fam Pract 2021; 38:441-447. [PMID: 33367646 PMCID: PMC8317217 DOI: 10.1093/fampra/cmaa139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES In the Netherlands, general practitioners (GPs) perform two-thirds of sexually transmitted infection (STI) consultations and diagnose one-third of HIV infections. GPs are, therefore, a key group to target to improve provider-initiated HIV testing. We describe the design and implementation of an educational intervention to improve HIV testing by Amsterdam GPs and explore trends in GPs' testing behaviour. METHODS Interactive sessions on HIV and STI using graphical audit and feedback started in 2015. Participating GPs developed improvement plans that were evaluated in follow-up sessions. Laboratory data on STI testing by Amsterdam GPs from 2011 to 2017 were collected for graphical audit and feedback and effect evaluation. The primary outcome was the HIV testing rate: number of HIV tests per 10 000 person-years (PY). Secondary endpoints were chlamydia and gonorrhoea testing rates and HIV positivity ratios. RESULTS Since 2015, 41% of GPs participated. HIV testing rate declined from 2011 to 2014 (from 175 to 116 per 10 000 PY), more in women than men (176 to 101 versus 173 to 132), and stabilized from 2015 to 2017. The HIV positivity ratio declined from 0.8% in 2011 to 0.5% in 2017. From 2011 to 2017, chlamydia and gonorrhoea testing rates declined in women (from 618 to 477 per 10 000 PY) but remained stable in men (from 270 to 278). CONCLUSIONS The stabilization of the downward trend in HIV testing coincided with this educational intervention. Follow-up data are needed to formally assess the intervention's impact on GP testing behaviour whilst considering contextual factors and secular trends.
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Affiliation(s)
- Saskia J Bogers
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten F Schim van der Loeff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Nynke van Dijk
- Department of General Practice, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karlijn Groen
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Marije L Groot Bruinderink
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Godelieve J de Bree
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Peter Reiss
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands.,Department of Global Health, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,HIV Monitoring Foundation, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan E A M van Bergen
- Department of General Practice, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,STI AIDS Netherlands, Amsterdam, the Netherlands
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56
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Yazdizadeh B, Walker R, Skouteris H, Olander EK, Hill B. Interventions improving health professionals' practice for addressing patients' weight management behaviours: systematic review of reviews. Health Promot Int 2021; 36:165-177. [PMID: 32447397 DOI: 10.1093/heapro/daaa039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Health professionals require education and training to implement obesity management guidelines and ultimately impact on the health outcomes experienced by their patients. Therefore, a systematic review of systematic reviews that evaluated interventions designed to change the practice of health professionals when addressing diet and physical activity with their patients was conducted. MEDLINE Complete; Cochrane database of systematic reviews; PsycINFO; CINAHL Complete; Global Health; Embase; INFORMIT: Health Subset; Health System Evidence and RX for change were searched in March 2019, with no date or language limits. Identified references underwent screening, full-text analyses and data extraction in duplicate. The search identified 15 230 references. Five systematic reviews that provided a narrative syntheses of a combined 38 studies were included. Health professional participants generally reported being satisfied with the training interventions. Heterogeneity between and within included reviews, non-controlled designs of individual studies and low quality of evidence at an individual study level and review level made it difficult to draw firm conclusions regarding what interventions are most effective in changing health professionals' knowledge, skills, self-efficacy, attitudes and practice. However, similar gaps in the literature were identified across included reviews. Key areas that could be addressed in future interventions including organization and system-level barriers to providing advice, health professionals' attitudes and motivation and weight stigma have been highlighted. Health professionals and patients could be more involved in the planning and development of interventions that work towards improving diet and physical activity advice and support provided in healthcare.
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Affiliation(s)
- Bahareh Yazdizadeh
- Knowledge Utilization Research Centre, Tehran University of Medical Sciences, 21, Dameshgh st, Vali-e Asr Avenue, Tehran 1416753955, Iran
| | - Ruth Walker
- School of Public Health and Preventive Medicine, Monash Centre for Health Research and Implementation, Monash University, 43-51 Kanooka Grove, Clayton, VIC 3168, Australia
| | - Helen Skouteris
- School of Public Health and Preventive Medicine, Monash Centre for Health Research and Implementation, Monash University, 43-51 Kanooka Grove, Clayton, VIC 3168, Australia
| | - Ellinor K Olander
- School of Health Sciences, Centre for Maternal and Child Health Research, City, University of London, London EC1V 0HB, UK
| | - Briony Hill
- School of Public Health and Preventive Medicine, Monash Centre for Health Research and Implementation, Monash University, 43-51 Kanooka Grove, Clayton, VIC 3168, Australia
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Daly BM, Arroll B, Scragg RKR. Trends in diabetes care and education by primary health care nurses in Auckland, New Zealand. Diabetes Res Clin Pract 2021; 177:108903. [PMID: 34102248 DOI: 10.1016/j.diabres.2021.108903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 05/04/2021] [Accepted: 06/03/2021] [Indexed: 11/24/2022]
Abstract
AIMS To examine trends in the management of patients with diabetes by primary health care nurses, its association with diabetes education and how valued and supported nurses feel in Auckland, New Zealand. METHODS Two representative cross-sectional surveys of all nurses providing community-based care, and patients with diabetes they consult, were conducted in 2006-8 and 2016. All participants completed a self-administered questionnaire on biographical details and a telephone interview on their provision of diabetes care. RESULTS Significantly more nurses discussed serum glucose and medications with patients, planned follow-up and scheduled practice nurse appointments in 2016 compared with 2006-8, and fewer specialist diabetologist appointments were made (12% versus 2%). Fewer nurses in 2016 than in 2006-8 felt valued (62% versus 75%) and supported (78% versus 89%) when managing patients (p-values = 0.0004). Nurses diabetes education was associated with recommended practice and feeling valued. Significantly more patients were prescribed metformin (81%) and insulin (46%) in 2016 compared with 58% and 30% in 2006-8. Despite this, HbA1c levels remained unchanged. CONCLUSIONS Prescribed glycaemic-related medications increased, and more nurses engaged with patients about glycaemic control and medications in 2016 compared with 2006-8. Nurses undertaking diabetes education was strongly associated with best management practices and nurses feeling valued.
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Affiliation(s)
- Barbara M Daly
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1142, New Zealand.
| | - Bruce Arroll
- School of Population Health, University of Auckland, New Zealand
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Identifying barriers, facilitators and behaviour change techniques to the adoption of the full scope of pharmacy practice among pharmacy professionals: Using the Theoretical Domains Framework. Res Social Adm Pharm 2021; 17:1396-1406. [PMID: 34165083 DOI: 10.1016/j.sapharm.2020.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/25/2020] [Accepted: 10/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND As pharmacy evolves, pharmacy professionals continue to struggle to practice to their full scope. A theoretically-informed intervention to change practice can support pharmacy professionals in providing full scope services. The Theoretical Domains Framework (TDF) can inform the design of a behaviour change intervention to improve the uptake of full scope services among pharmacy professionals. OBJECTIVES This study aimed to: (1) identify barriers and facilitators influencing the adoption of full scope services among pharmacy professionals, and (2) identify optimal behaviour change techniques (BCTs) to address the identified barriers and facilitators. METHODS A three-step, mixed method study was conducted. First, a 24-item TDF-based survey was sent via email to users of a national computer-based educational platform (n = 2696). Second, TDF-based interviews were conducted with a convenient sample of survey respondents and analyzed using the framework method. Finally, validated linkages were used to link BCTs with corresponding barriers and facilitators, then interview data were analyzed using a deductive approach to guide the selection of the BCTs. RESULTS A total of 225 participants completed the survey and 24 telephone interviews were conducted (17 pharmacists, 7 pharmacy technicians). A number of key barriers were identified on an individual level (e.g., lack of clear professional identity and limited decision-making skills in ambiguous cases) and on an organizational level (e.g., lack of social support from managers and concerns about making more errors with the current workflow). Mapping the barriers and facilitators to BCTs yielded 18 BCTs to support the adoption of full scope services, including modeling, rehearsal/practice, and social support. CONCLUSIONS This study highlighted several barriers that need to be addressed to facilitate pharmacy professionals working to their full scope, including professional collaboration, professional identity, and adequate training. A comprehensive intervention combining skills training with modeling, social support, and decision-making tools could encourage practice change.
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Wurz A, McLaughlin E, Lategan C, Chamorro Viña C, Grimshaw SL, Hamari L, Götte M, Kesting S, Rossi F, van der Torre P, Guilcher GMT, McIntyre K, Culos-Reed SN. The international Pediatric Oncology Exercise Guidelines (iPOEG). Transl Behav Med 2021; 11:1915-1922. [PMID: 34037786 PMCID: PMC8604278 DOI: 10.1093/tbm/ibab028] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Physical activity (PA) and exercise are safe and beneficial for children and
adolescents affected by cancer. Yet, this population is not active enough to
receive benefits. PA guideline and recommendation statements can support
individual behavior and practice change. The purpose of this project was to
develop the international Pediatric Oncology Exercise Guidelines (iPOEG),
comprised of guideline and recommendation statements, to promote PA among
children and adolescents affected by cancer. Guideline development procedures,
stakeholder engagement strategies, and the Delphi technique were used. Four
online surveys were distributed to the iPOEG network (n = 9
core team members, n = 122 expert consensus committee members).
Surveys included closed- and open-ended items informed by a literature synthesis
and an in-person meeting. Responses were analyzed using descriptive statistics
and content analysis. Consensus was defined as ≥ 80% agreement. Response
rates to online surveys ranged from 82% to 91%. The iPOEG network agreed on four
guideline and five recommendation statements, which highlight that movement is
important for all children and adolescents affected by cancer. These statements
are generic in nature as more research is still required to provide specific
guidance on the frequency, intensity, time, and type of PA for this population.
Nevertheless, the iPOEG statements represent available evidence and expert
opinion, collectively suggesting that it is time for children and adolescents
affected by cancer to move more. Physical activity is safe and beneficial for children and adolescents affected by
cancer. Yet, most are not active enough to receive benefits. Guideline and
recommendation statements can help change individual behavior and practice. To
develop such statements, guideline development procedures, stakeholder
engagement strategies, and the Delphi technique were used. Four online surveys
were distributed to an international network (n = 131 experts).
Surveys asked closed- and open-ended questions informed by a literature
synthesis and an in-person meeting. Findings from the online surveys resulted in
the international Pediatric Oncology Exercise Guidelines statements, which
highlight that it is time for children and adolescents affected by cancer to
move more.
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Affiliation(s)
- Amanda Wurz
- Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Emma McLaughlin
- Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Conné Lategan
- Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Carolina Chamorro Viña
- Faculty of Kinesiology, University of Calgary, Calgary, Canada.,Kids Cancer Care Foundation of Alberta, Calgary, Canada
| | | | - Lotta Hamari
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Miriam Götte
- Clinic for Pediatrics III, Department of Pediatric Hematology/Oncology, University Hospital Essen, Essen, Germany
| | - Sabine Kesting
- Kinderklinik München Schwabing, TUM School of Medicine, Department of Pediatrics and Children's Cancer Research Center, TUM, Munich, Germany
| | - Francesca Rossi
- Rehabilitation Service, Public Health and Pediatric Sciences Department, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Patrick van der Torre
- Sport and Exercise Center, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Gregory M T Guilcher
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Section of Oncology/Bone Marrow Transplant, Alberta Children's Hospital, Calgary, Canada
| | - Krista McIntyre
- Section of Oncology/Bone Marrow Transplant, Alberta Children's Hospital, Calgary, Canada
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Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, Law RJ, Hiscock J, Carson-Stevens A, Neal RD, Wilkinson C. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot Feasibility Stud 2021; 7:100. [PMID: 33883033 PMCID: PMC8059131 DOI: 10.1186/s40814-021-00834-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/07/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. METHODS The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. DISCUSSION This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04823559 .
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Affiliation(s)
- Stefanie Disbeschl
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK.
| | - Alun Surgey
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Jessica L Roberts
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Annie Hendry
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Nefyn Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, L69 3GL, UK
| | - Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, UHW Main Building, Heath Park, Cardiff, CF14 4XN, UK
| | - Richard D Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
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Ragusa R, Marranzano M, Lombardo A, Quattrocchi R, Bellia MA, Lupo L. Has the COVID 19 Virus Changed Adherence to Hand Washing among Healthcare Workers? Behav Sci (Basel) 2021; 11:53. [PMID: 33920791 PMCID: PMC8071195 DOI: 10.3390/bs11040053] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
The aim of the study was to assess adherence to hand washing by healthcare workers (HCWs) and its variations over time in hospital wards. We wanted to check whether the pandemic had changed the behavior of HCWs. The study was conducted between 1 January 2015, and 31 December 2020. The HCWs were observed to assess their compliance with the Five Moments for Hand Hygiene. We described the percentage of adherence to World Health Organization (WHO) guidelines stratified per year, per specialty areas, per different types of HCWs. We also observed the use of gloves. Descriptive data were reported as frequencies and percentages. We observed 13,494 hand hygiene opportunities. The majority of observations concerned nurses who were confirmed as the category most frequently involved with patients. Hospital's global adherence to WHO guidelines did not change in the last six years. During the pandemic, the rate of adherence to the procedure increased significantly only in Intensive Care Unit (ICU). In 2020, the use of gloves increased in pre-patient contact. The hand-washing permanent monitoring confirmed that it is very difficult to obtain the respect of correct hand hygiene in all opportunities, despite the ongoing pandemic and the fear of contagion.
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Affiliation(s)
- Rosalia Ragusa
- Health Technology Assessment Committee, University Hospital “G. Rodolico”, Via Santa Sofia, 78 95123 Catania, Italy
| | - Marina Marranzano
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Via Santa Sofia, 87 95123 Catania, Italy; (M.M.); (L.L.)
| | - Alessandro Lombardo
- Committee for the Control of Hospital Infections, University Hospital “G. Rodolico”, Via Santa Sofia, 78 95128 Catania, Italy;
| | - Rosalba Quattrocchi
- U.O. Health Education, University Hospital “G. Rodolico”, Via Santa Sofia, 78 95128 Catania, Italy;
| | - Maria Alessandra Bellia
- School of Specialization in Microbiology, University of Catania, Via Santa Sofia, 78 95123 Catania, Italy;
| | - Lorenzo Lupo
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Via Santa Sofia, 87 95123 Catania, Italy; (M.M.); (L.L.)
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Nabovati E, Jeddi FR, Farrahi R, Anvari S. Information technology interventions to improve antibiotic prescribing for patients with acute respiratory infection: a systematic review. Clin Microbiol Infect 2021; 27:838-845. [PMID: 33813115 DOI: 10.1016/j.cmi.2021.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 01/19/2021] [Accepted: 03/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Information technology (IT) interventions provide physicians with easy and quick access to information at the point of care and can play a major role in clinical decision-making for antibiotic prescribing. This study aimed to examine the effects and characteristics of IT interventions on improving antibiotic prescribing for patients with acute respiratory infection (ARI). METHODS A comprehensive search was performed in Medline (through PubMed), ISI web of science, Embase, and Cochrane databases from inception to 31 August 2020. Randomized controlled trial (RCT) and cluster RCT (CRCT) studies examining the effectiveness of IT interventions in improving antibiotic prescribing for patients with ARI were included. Participants were patients with ARI. IT interventions were used for improving antibiotic prescribing. Two researchers independently extracted data from studies on methods, characteristics of interventions, and results. The characteristics of interventions were extracted based on three dimensions of IT design, data entry source, and implementation characteristics. RESULTS Eighteen studies (15 CRCTs and three RCTs) were included. Most of included studies (n = 11) were conducted in the United States. In 12 studies (66.7%), IT interventions improved the level of antibiotic prescribing, and in eight of the 12 studies the effect was statistically significant. In two studies the intervention had a statistically significant negative effect, and in two studies the level of antibiotic prescribing was not changed. Seventeen studies (94.4%) used clinical decision support systems (CDSSs) for the intervention. In 12 studies (66.7%) CDSSs were integrated with electronic health records (EHRs). CONCLUSIONS Information technology interventions have the potential to improve prescription of antibiotics for patients with acute respiratory infection and to change physicians' behaviours in this regard. Factors affecting the acceptance of IT-based interventions to improve prescription of antibiotics should be investigated in future studies.
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Affiliation(s)
- Ehsan Nabovati
- Health Information Management Research Centre, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran.
| | - Fatemeh Rangraz Jeddi
- Health Information Management Research Centre, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Razieh Farrahi
- Student Research Committee, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran.
| | - Shima Anvari
- Student Research Committee, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran
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Toomey M, Gyawali R, Stapleton F, Ho KC, Keay L, Jalbert I. Facilitators and barriers to the delivery of eye care by optometrists: a systematic review using the theoretical domains framework. Ophthalmic Physiol Opt 2021; 41:782-797. [PMID: 33774856 DOI: 10.1111/opo.12801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/21/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE Evidence-based practice is fundamental to providing quality care, patient satisfaction and judicious use of limited healthcare resources. However, variability in evidence-based eye care delivery has been reported. Given the important role of optometrists in delivering primary eye care, a better understanding of the barriers and facilitators to providing optometric care is required. This systematic review aimed to identify determinants (barriers and facilitators) of eye care delivery by optometrists and interventions that may improve eye care delivery. RECENT FINDINGS PubMed, MEDLINE, EMBASE, CINAHL, SCOPUS, PsychINFO, ProQuest and Web of Science were searched for studies reporting barriers and facilitators to eye care delivery published between 1999 and 2020. The Theoretical Domains Framework (TDF) was used to analyse data (quotations, interpretive summaries, survey result) with barriers and facilitators coded to one or more of the 14 domains, and used to identify the key behavioural domains influencing eye care delivery based on frequency of coding, elaboration and stated importance in the study. Influential domains were mapped to the Behaviour Change Wheel to identify potential interventions to improve eye care delivery. Of the 802 studies retrieved from the search, 30 were included. Frequently identified barriers were time constraints, resources and equipment issues, patient factors, lack of awareness, skill proficiency deficits and negative attitudes and beliefs. Frequently identified facilitators were adequate time, resources and equipment, education, skill proficiency and understanding the relevancy of the eye care provided. The key TDF domains influencing eye care delivery were 'environmental context and resources' (time, resources, equipment issues, patient factors), 'knowledge' (awareness issues), 'skills' (skills proficiency) and 'belief about consequences' (beliefs and relevancy). Intervention functions that may improve eye care delivery were education, training, restriction, environmental restructuring, enablement, persuasion and modelling. SUMMARY The barriers and facilitators identified in this review were diverse and located at both the practitioner and organisational levels. Four TDF domains were found to be influential determinants of eye care practice. Intervention functions identified in this study can be used to improve the appropriateness of primary eye care delivery.
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Affiliation(s)
- Melinda Toomey
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Rajendra Gyawali
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Fiona Stapleton
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Kam Chun Ho
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.,Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lisa Keay
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.,The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Isabelle Jalbert
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
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Knowledge, Attitude, and Practices on Drug-Resistant Tuberculosis Infection Control in Nepal: A Cross-Sectional Study. Tuberc Res Treat 2021; 2021:6615180. [PMID: 33747563 PMCID: PMC7943263 DOI: 10.1155/2021/6615180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 11/22/2022] Open
Abstract
Drug-resistant tuberculosis (DR-TB) transmission is an important problem, particularly in low-income settings. This study is aimed at assessing the knowledge, attitude, and practices of DR-TB infection control among the healthcare workers under the National Tuberculosis Control Program in Nepal. In this cross-sectional study, we studied the healthcare workers from all the 11 functioning DR-TB treatment centers across Nepal in March 2018. Through face-to-face interviews, trained data collectors collected data on the characteristics of healthcare workers, their self-reported knowledge, attitude, and practice on DR-TB infection control. We entered the data in Microsoft Excel and analyzed in the R statistical software. We assigned a score of one to the correct response and zero to the incorrect or no response and calculated a composite score in each of the knowledge, attitude, and practice domains. We ascertained the healthcare workers as having good knowledge, appropriate attitude, and optimal practices when the composite score was ≥50%. We summarized the numerical variables with median (interquartile range (IQR)) and the categorical variables with proportions. We ran appropriate correlation tests to identify relationships between knowledge, attitude, and practice scores. We regarded a p value of <0.05 as significant. A total of 95 out of 102 healthcare workers responded. There were 46 male respondents. The median age was 33 years (IQR 26-42). Most of them (53, 55.79%) were midlevel paramedics. We found 91 (95.79%) respondents had good knowledge, 49 (51.58%) had an appropriate attitude, and 35 (36.84%) had optimal practices on DR-TB infection control. We found a statistically significant positive correlation between attitude and practice scores (ρ = 0.37, p ≤ 0.001). The healthcare workers at the DR-TB treatment centers in Nepal have good knowledge of DR-TB infection control, but it did not translate into an appropriate attitude or optimal practices.
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Shahmoradi L, Safdari R, Ahmadi H, Zahmatkeshan M. Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects. Med J Islam Repub Iran 2021; 35:27. [PMID: 34169039 PMCID: PMC8214039 DOI: 10.47176/mjiri.35.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi
- OIM Department, Aston Business School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Maryam Zahmatkeshan
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
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Ahmed K, Hashim S, Khankhara M, Said I, Shandakumar AT, Zaman S, Veiga A. What drives general practitioners in the UK to improve the quality of care? A systematic literature review. BMJ Open Qual 2021; 10:e001127. [PMID: 33574115 PMCID: PMC7880106 DOI: 10.1136/bmjoq-2020-001127] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated. OBJECTIVES (1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature. METHODS This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes. RESULTS 35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition. DISCUSSION The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care. CONCLUSION Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.
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Affiliation(s)
- Kanwal Ahmed
- School of Medicine, Imperial College London, London, London, UK
| | - Salma Hashim
- School of Medicine, Imperial College London, London, London, UK
| | | | - Ilhan Said
- School of Medicine, Imperial College London, London, London, UK
| | | | - Sadia Zaman
- School of Medicine, Imperial College London, London, London, UK
| | - Andre Veiga
- Business School, Imperial College London, London, London, UK
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Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial. J Gen Intern Med 2021; 36:305-312. [PMID: 32845446 PMCID: PMC7878643 DOI: 10.1007/s11606-020-06134-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antibiotics prescribed for acute respiratory tract infections in the telemedicine setting are often unwarranted. OBJECTIVE We hypothesized that education plus individualized feedback, compared with education alone, would significantly reduce antibiotic prescription rates for upper respiratory infections, bronchitis, sinusitis, and pharyngitis in a telemedicine setting. DESIGN Two-arm, parallel-group randomized controlled trial conducted at a telemedicine practice from January 1, 2018, to November 30, 2018. PARTICIPANTS Clinicians employed at the practice on or after January 1, 2017 (n = 45). INTERVENTIONS The control group received education (treatment guideline presentation and online course) in April 2018. The intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide antibiotic prescription rates starting May 2018. MAIN MEASURES Antibiotic prescription for any visit with at least one target condition: upper respiratory tract infection, bronchitis, sinusitis, and pharyngitis. KEY RESULTS Baseline antibiotic prescription rates in control and intervention groups across conditions were as follows: upper respiratory infection (URI): 626/3410 (18.4%), 413/2752 (15.0%), bronchitis: 689/1471 (46.8%), 742/1162 (64.0%), sinusitis: 5154/6131 (84.1%), 4250/4876 (87.2%), pharyngitis: 2308/2838 (81.3%), 1593/2126 (74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period, for both control and intervention groups. Reduction of antibiotic prescriptions for URI and bronchitis was greater for the group receiving education plus individualized feedback compared with that for the group receiving education alone (interaction term ratio 0.60, 95% CI 0.47 to 0.77 for URI; and interaction term ratio 0.42, 95% CI 0.32 to 0.55 for bronchitis), but not sinusitis and pharyngitis. CONCLUSION Education plus individualized feedback in a telemedicine practice significantly decreased antibiotic prescription rates for upper respiratory tract infections and bronchitis, compared with education alone. Future studies should focus on tailoring antibiotic stewardship programs based on underlying conditions, and the maintenance of early reductions in antibiotic prescription.
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Shafat T, Shimoni O, Nikonov A, Nesher L. The Kinetics of an Antibiotic Stewardship Intervention: A Quasi-Experimental Study. Infect Dis Ther 2021; 10:613-619. [PMID: 33515415 PMCID: PMC7954991 DOI: 10.1007/s40121-021-00403-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Little is known about the kinetics and different phases of a successful antibiotic stewardship program (ASP) intervention. Methods We analyzed the trends of quarterly antibiotic use measured in defined daily dose (DDD)/100 days hospitalization using the Joinpoint Regression Program and interrupted time series analysis to objectively identify shifts in the trends of antibiotic use. We correlated these changes in trends with the introduction of a hospital-wide ASP intervention. Results The ASP intervention reduced the overall antibiotic use by 33%, from a prior steady state of 76.5 DDD/100 days hospitalization to a post-intervention steady state of 51.2 DDD/100 days hospitalization (p < 0.001). We identified four distinct phases in the trends: prior steady state (A), early intervention (B), accelerated phase (C), and post steady state (D). From A to B a change of slope (−1.46) [SE 0.37, 95% CI −2.23, −0.69 (p = 0.002)]; B to C, a further decrease of slope (−4.70) [SE 0.64, 95% CI −6.03, −3.37 (p = 0.001)]; between periods C and D, straightening out of the slope (+ 6.84) [SE 0.55, 95% CI 5.70, 7.98 (p < 0.001)] to a new post-intervention steady state. It took 1.5 years after completion of the intervention to reach the new steady state. Conclusions We demonstrate that ASP interventions require time to achieve the maximal effect. Successful interventions require physicians to adapt new prescribing behaviors and gain confidence in the change; this adaptation can be a prolonged process and might even take years after the introduction of the ASP. These factors should be considered when planning and implementing ASP interventions.
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Affiliation(s)
- Tali Shafat
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Clinical Research Center, Soroka University Medical Center, Beer Sheba, Israel
| | - Orly Shimoni
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Pharmacy Services, Soroka University Medical Center, Beer Sheba, Israel
| | - Anna Nikonov
- Pharmacy Services, Soroka University Medical Center, Beer Sheba, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel. .,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.
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Etchegary C, Taylor L, Mahoney K, Parfrey O, Hall A. Changing Health-Related Behaviours 5: On Interventions to Change Physician Behaviours. Methods Mol Biol 2021; 2249:613-630. [PMID: 33871867 DOI: 10.1007/978-1-0716-1138-8_33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In many countries, there is a large amount of public money spent on health care. Some patient tests and treatments are not only unnecessary but also may be harmful, leading health researchers to look for the most effective interventions to change physician behaviour. The purpose of this chapter is to describe some of the interventions used to modify physician behaviour and highlight their challenges observed in a Canadian provincial context. We begin with a brief description of the increasing interest in behaviour change interventions in recent years and their theoretical basis. We then describe several interventions used to change physician behaviour ranging from nudges to choice restriction and the available evidence on their effectiveness. We provide examples of interventions and their challenges as we've experienced them in our research program, Quality of Care NL. We conclude with a summary of what the evidence tells us about interventions to change physicians' behaviours.
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Affiliation(s)
- Cheryl Etchegary
- Quality of Care NL, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada.
| | - Lynn Taylor
- Quality of Care NL, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Krista Mahoney
- Quality of Care NL, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Owen Parfrey
- Quality of Care NL, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, St. John's, NL, Canada
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Perkins RB, Banigbe B, Fenton AT, O’Grady AK, Jansen EM, Bernstein JL, Joseph NP, Eun TJ, Biancarelli DL, Drainoni ML. Effect of a multi-component intervention on providers' HPV vaccine communication. Hum Vaccin Immunother 2020; 16:2736-2743. [PMID: 32401592 PMCID: PMC7734092 DOI: 10.1080/21645515.2020.1747923] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022] Open
Abstract
Objective: To evaluate the effect of a multi-component intervention including communication training on provider beliefs and recommendation practices around the human papillomavirus (HPV) vaccine using both self-reports and audio-recordings of clinical interactions. Methods: We conducted a mixed method study at five family medicine and pediatric practices. Providers self-reported beliefs and practices about HPV vaccination via surveys and qualitative interviews conducted pre- and post-intervention. We also assessed provider recommendation style using audio-recordings of clinical interactions pre- and post-intervention. Content analysis was used to identify themes in qualitative interviews. Matched pre- and post-intervention surveys were analyzed for changes in provider beliefs and attitudes. Pre- and post-intervention audio recordings of clinical interactions were analyzed for observed differences in recommendation styles. Bivariate analyses of quantitative data used Chi-square and Fisher's exact tests; t-tests were used for continuous variables. Results: Providers reported in interviews that the intervention led to communication changes by increasing their knowledge, reframing the HPV vaccine as a routine vaccination, and providing tools for engaging with parents. Surveys indicated that the proportion of providers reporting that the HPV vaccine is one of the most important adolescent vaccines increased from 71% pre-intervention to 100% post-intervention (p = .03). Audio-recording analysis demonstrated that use of an indicated (presumptive) recommendation style increased from 62.5% pre-intervention to 79.6% post-intervention (p = .047). Conclusions: Educating providers about HPV vaccination and giving them tools to facilitate communication with parents can reframe HPV as a routine adolescent vaccination and motivate providers to routinely use effective recommendation styles in practice.
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Affiliation(s)
- Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | | | - Anny T. Fenton
- Maine Medical Center Research Institute, Center for Outcomes, Research, & Evaluation (CORE), Portland, ME, USA
| | | | - Emily M. Jansen
- Boston University School of Medicine, Continuing Medical Education Office, Boston, MA, USA
| | - Judith L. Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Natalie P. Joseph
- Department of Pediatrics and Adolescent Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | - Terresa J. Eun
- Department of Sociology, Stanford University, Stanford, CA, USA
| | - Dea L. Biancarelli
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mari-Lynn Drainoni
- Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Evans Center for 10 Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
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van Dulmen SA, Naaktgeboren CA, Heus P, Verkerk EW, Weenink J, Kool RB, Hooft L. Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis. BMJ Open 2020; 10:e040025. [PMID: 33127636 PMCID: PMC7604848 DOI: 10.1136/bmjopen-2020-040025] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/28/2020] [Accepted: 09/30/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess barriers and facilitators to de-implementation. DESIGN A qualitative evidence synthesis with a framework analysis. DATA SOURCES Medline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched. ELIGIBILITY CRITERIA We included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy. DATA EXTRACTION AND SYNTHESIS The factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context. RESULTS We identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%). CONCLUSIONS This study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.
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Affiliation(s)
- S A van Dulmen
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C A Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrech, Utrecht University, Utrecht, The Netherlands
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eva W Verkerk
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Weenink
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rudolf Bertijn Kool
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
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Roquilly A, Chanques G, Lasocki S, Foucrier A, Fermier B, De Courson H, Carrie C, Danguy des Deserts M, Gakuba C, Constantin JM, Lagarde K, Holleville M, Blidi S, Sossou A, Cailliez P, Monard C, Oudotte A, Mathieu C, Bourenne J, Isetta C, Perrigault PF, Lakhal K, Rouhani A, Asehnoune K, Guerci P, Tran Dinh A, Chousterman B, Cupaciu A, Dahyot-Fizelier C, Bellier R, Au Duong J, Mansour A, Morel J, Beauplet G, Vibet MA, Feuillet F, Sébille V, Leone M. Implementation of French recommendations for the prevention and the treatment of hospital-acquired pneumonia: a cluster-randomized trial. Clin Infect Dis 2020; 73:e1601-e1610. [PMID: 32970811 DOI: 10.1093/cid/ciaa1441] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We determined whether an audit on the adherence to guidelines for hospital-acquired pneumonia (HAP) for can improve the outcomes of patients in intensive care units (ICUs). METHODS This study was conducted at 35 ICUs in 30 hospitals. We included consecutive adult patients hospitalized in ICUs for three days or more. After a three-month baseline period followed by the dissemination of recommendations, an audit on the compliance to recommendations (audit period) was followed by a three-month cluster-randomized trial. We randomly assigned ICUs to either audit and feedback (intervention group) or participation to a national registry (control group). The primary outcome was the duration of ICU stay. RESULTS Among 1,856 patients enrolled, 602, 669, and 585 were recruited in the baseline, audit, and intervention periods, respectively. The composite measure of compliance was 47(38-56)% in the intervention group and 42(25-53)% in the control group (p=0.001). As compared to the baseline period, the ICU length of stay was reduced by 3.2 days in the intervention group (p=0.07) and by 2.8 days in the control group (p=0.02). The duration of ICU stay was 7 (5-14) in the control group and 9 (5-20) days in the intervention group (p=0.10). After adjustment for unbalanced baseline characteristics, the hazard ratio for being discharged alive from ICU in the control group was 1.17 (95% CI, 0.69 to 2.01; p=0.10). CONCLUSIONS The publication of French guidelines for HAP was associated with a reduction of the ICU length of stay. However, the realization of an audit to improve their application did not further improve outcomes.
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Affiliation(s)
- Antoine Roquilly
- Department of Anesthesiology and Critical Care, Hotel Dieu, CHU Nantes, Nantes, France.,Laboratory EA3826, Faculty of Medicine, University of Nantes, Nantes, France
| | - Gérald Chanques
- Surgical Intensive Care Unit, Centre Hospitalier Universitaire, Montpellier, France
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Arnaud Foucrier
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire de Beaujon (AP/HP), Beaujon, France
| | - Brice Fermier
- Intensive Care Unit, Simone Veil Hospital, Blois, France
| | - Hugues De Courson
- Department of Neuro-Critical Care, Pellegrin Hospital, Bordeaux, France
| | - Cedric Carrie
- Surgical and trauma Intensive Care, Pellegrin Hospital, Bordeaux, France
| | - Marc Danguy des Deserts
- Department of Anesthesiology and Critical Care, Hospital Inter-Armée Clermont Tonnerre, Brest, France
| | - Clément Gakuba
- Department of Anesthesiology and Critical Care, CHU Caen, Caen, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Hôpital Gabriel Montpied, CHU Clermont Ferrand, Clermont-Ferrand, France
| | - Kevin Lagarde
- Neuroréanimation-Anesthésie Neuroradiologie Interventionnelle, Hôpital Gabriel Montpied, CHU Clermont Ferrand, Clermont-Ferrand, France
| | | | - Sami Blidi
- Intensive Care Unit, Eaubonne Hospital, Eaubonne, France
| | - Achille Sossou
- Department of Anesthesiology and Critical Care, Emile Roux Hospital, Le Puy en Velay, France
| | | | - Celine Monard
- Department of Anesthesiology and Critical Care, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Adrien Oudotte
- Department of Neuro-Critical Care, Hospices Civils de Lyon, Lyon, France
| | - Calypso Mathieu
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Department of Anesthesiology and Critical Care Medicine, Hôpital Nord, Marseille, France
| | - Jeremy Bourenne
- Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Emergency Intensive Care Unit, Hopital la Timone, Marseille, France
| | - Christian Isetta
- Department of Anesthesiology and Cardiothoracic Intensive Care, Pierre Zobda-Quitman, Martinique, France
| | | | - Karim Lakhal
- Department of Anesthesiology and Critical Care, Guillaume and Rene Laennec Hospital, CHU Nantes, Nantes, France
| | - Armine Rouhani
- Severe Burn Intensive Care Unit, Hotel Dieu, CHU Nantes, Nantes, France
| | - Karim Asehnoune
- Department of Anesthesiology and Critical Care, Hotel Dieu, CHU Nantes, Nantes, France.,Laboratory EA3826, Faculty of Medicine, University of Nantes, Nantes, France
| | - Philippe Guerci
- Surgical Intensive Care Unit, Centre Hospitalier Universitaire, Nancy, France
| | - Alexy Tran Dinh
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire de Bichat (AP/ HP), Paris, France
| | - Benjamin Chousterman
- Department of Anesthesiology and Critical Care, Severe Burn Unit, Centre Hospitalier Universitaire de Lariboisiere (AP/HP), Paris, France
| | - Alexandru Cupaciu
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire de Saint Louis (AP/ HP), Paris, France
| | | | - Remy Bellier
- Neuro-Intensive Care Unit, Centre Hospitalier Universitaire, Poitiers, France
| | - Jonathan Au Duong
- Intensive Care Unit, Department of Anesthesiology and Critical Care, Rangueil Hospital, Centre Hospitalier Universitaire, Toulouse, France
| | - Alexandre Mansour
- Department of Anesthesiology and Critical Care, Pontchaillou Hospital, CHU Rennes, Rennes, France
| | - Jérome Morel
- Department of Anesthesiology and Critical Care, CHU Saint Etienne, Saint Etienne, France
| | - Ghilain Beauplet
- Department of Anesthesiology, Intensive care and Perioperative medicine - Hautepierre Hospital, Strasbourg, France
| | - Marie-Anne Vibet
- Microbiotas Hosts Antibiotics Bacterial Resistances (MiHAR), Université de Nantes, Nantes, France.,DRCI, Plateforme de Méthodologie et de Biostatistique, CHU Nantes, Nantes, France
| | - Fanny Feuillet
- DRCI, Plateforme de Méthodologie et de Biostatistique, CHU Nantes, Nantes, France.,UMR INSERM U1246 - SPHERE "methodS in Patient-centered outcomes & HEalth ResEarch" Université de Nantes, Université de Tours, France
| | - Véronique Sébille
- DRCI, Plateforme de Méthodologie et de Biostatistique, CHU Nantes, Nantes, France.,UMR INSERM U1246 - SPHERE "methodS in Patient-centered outcomes & HEalth ResEarch" Université de Nantes, Université de Tours, France
| | - Marc Leone
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Department of Anesthesiology and Critical Care Medicine, Hôpital Nord, Marseille, France
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Embry J, Reis MD, Couchman G, Ledbetter TG, Zolfaghari K. Quality improvement initiative for pain management practices in primary care. Proc AMIA Symp 2020; 33:513-519. [PMID: 33100518 PMCID: PMC7549893 DOI: 10.1080/08998280.2020.1814181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022] Open
Abstract
In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing.
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Affiliation(s)
- Judy Embry
- Department of Family Medicine, Baylor Scott & White Health, Temple, Texas
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
| | - Michael D. Reis
- Department of Family Medicine, Baylor Scott & White Health, Temple, Texas
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
| | - Glen Couchman
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
- Chief Medical Officer of Clinical Operations, Baylor Scott & White Health, Dallas, Texas
| | - T. Glenn Ledbetter
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
- Quality Alliance Board of Managers, Baylor Scott & White Health, Dallas, Texas
| | - Kiumars Zolfaghari
- Center for Applied Health Research, Baylor Scott & White Health, Temple, Texas
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74
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Bion J, Brookes O, Brown C, Tarrant C, Archer J, Buckley D, Buckley LM, Clement I, Evison F, Smith FG, Gibbins C, Hayton EJ, Jones J, Lilford R, Mullhi R, Packer G, Perkins GD, Shelton J, Snelson C, Sullivan P, Vlaev I, Wolstenholme D, Wright S. A framework and toolkit of interventions to enhance reflective learning among health-care professionals: the PEARL mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background
Although most health care is high quality, many patients and members of staff can recall episodes of a lack of empathy, respect or effective communication from health-care staff. In extreme form, this contributes to high-profile organisational failures. Reflective learning is a universally promoted technique for stimulating insight, constructive self-appraisal and empathy; however, its efficacy tends to be assumed rather than proven. The Patient Experience And Reflective Learning (PEARL) project has used patient and staff experience to co-design a novel reflective learning framework that is based on theories of behaviour and learning.
Objective
To create a toolkit to help health-care staff obtain meaningful feedback to stimulate effective reflective learning that will promote optimal patient-, family- and colleague-focused behaviours.
Design
A 3-year developmental mixed-methods study with four interlinked workstreams and 12 facilitated co-design meetings. The Capability, Opportunity, Motivation – Behaviour framework was used to describe factors influencing the behaviour of reflection.
Setting
This took place at five acute medical units and three intensive care units in three urban acute hospital trusts in England.
Participants
Patients and relatives, medical and nursing staff, managers and researchers took part.
Data sources
Two anonymous surveys, one for patients and one for staff, were developed from existing UK-validated instruments, administered locally and analysed centrally. Ethnographers undertook interviews and observed clinical care and reflective learning activities in the workplace, as well as in the co-design meetings, and fed back their observations in plenary workshops.
Main outcome measures
Preliminary instruments were rated by participants for effectiveness and feasibility to derive a final set of tools. These are presented in an attractively designed toolbox with multiple sections, including the theoretical background of reflection, mini guides for obtaining meaningful feedback and for reflecting effectively, guides for reflecting ‘in-action’ during daily activities, and a set of resources.
Results
Local project teams (physicians, nurses, patients, relatives and managers) chaired by a non-executive director found the quarterly reports of feedback from the patient and staff surveys insightful and impactful. Patient satisfaction with care was higher for intensive care units than for acute medical units, which reflects contextual differences, but in both settings quality of communication was the main driver of satisfaction. Ethnographers identified many additional forms of experiential feedback. Those that generated an emotional response were particularly effective as a stimulus for reflection. These sources of data were used to supplement individual participant experiences in the nine local co-design meetings and four workshops to identify barriers to and facilitators of effective reflection, focusing on capability, opportunity and motivation. A logic model was developed combining the Capability, Opportunity, Motivation – Behaviour framework for reflection and theories of learning to link patient and staff experience to changes in downstream behaviours. Participants proposed practical tools and activities to enhance reflection ‘in-action’ and ‘on-action’. These tools were developed iteratively by the local and central project teams.
Limitations
Paper-based surveys were burdensome to administer and analyse.
Conclusions
Patients and health-care staff collaborated to produce a novel reflective learning toolkit.
Future work
The toolkit requires evaluating in a cluster randomised controlled trial.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julian Bion
- Department of Anaesthesia & Intensive Care Medicine, University of Birmingham, Birmingham, UK
| | - Olivia Brookes
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Celia Brown
- Population Evidence and Technologies, University of Warwick, Coventry, UK
| | - Carolyn Tarrant
- Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Julian Archer
- Royal Australasian College of Surgeons, Melbourne, VIC, Australia
| | - Duncan Buckley
- Patient and Public Involvement Representative, Birmingham, UK
| | | | - Ian Clement
- Critical Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Felicity Evison
- Informatics Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Fang Gao Smith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Chris Gibbins
- Acute Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Emma-Jo Hayton
- Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jennifer Jones
- Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Lilford
- Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK
| | - Randeep Mullhi
- Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Greg Packer
- Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin D Perkins
- Critical Care Medicine, Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Jonathan Shelton
- Critical Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Catherine Snelson
- Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Sullivan
- Acute Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ivo Vlaev
- Behavioural Science Group, University of Warwick, Coventry, UK
| | - Daniel Wolstenholme
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber, Sheffield, UK
| | - Stephen Wright
- Critical Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Deo N, Johnson E, Kancharla K, O'Horo JC, Kashyap R. Instant Gratification as a Method to Promote Physician Practice Guideline Adherence: A Systematic Review. Cureus 2020; 12:e9381. [PMID: 32850248 PMCID: PMC7445093 DOI: 10.7759/cureus.9381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Inadequate adherence to best practice guidelines may have a negative impact on the processes of critical care and patient outcomes. Instant gratification has been used to modify human behavior in industries such as gaming, lottery, and social media. We hypothesize that, if properly and purposefully utilized, IG can become a successful tool for encouraging best practice guideline adherence among critical care providers. Four major databases were searched with a medial librarian. Covidence application was used to identify studies pertaining to the instant gratification being used to improve provider adherence with best practice guidelines. A total of 712 studies were identified, and, through duplicates removal, title and abstract screening, and full-text screening, a total of 13 studies were included in the final review. The exclusion criteria used included the following: no provider gratification, wrong focus/intervention, wrong study design, patient-focused intervention, not generalizable, and no conclusion. There is a knowledge gap regarding instant gratification utilization to influence practice guideline adherence among providers. The intervention functions of the Behavior Change Wheel (BCW) were evident, especially 'persuasion' and 'incentivization', which are most pertinent to our field. The restorative process that promotes positive reinforcement can be a potential solution for alleviating inadequacies in guideline adherence. Examining interventions based on functions of the BCW has shown that an instant gratification process may have the potential in altering critical care providers' behavior and improving guideline adherence. This review is the first step towards creating smart algorithms to instantly alert providers for their actions compliant with best practices. Developing, testing, and validating the algorithms will be the next several steps.
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Affiliation(s)
- Neha Deo
- Medicine, Mayo Clinic Alix School of Medicine, Rochester, USA
| | - Emily Johnson
- Medicine, Oklahoma State University, Stillwater, USA
| | | | - John C O'Horo
- Infectious Diseases and Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
| | - Rahul Kashyap
- Critical Care, Mayo Clinic and Foundation, Rochester, USA
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Hammar T, Hellström L, Ericson L. The Use of a Decision Support System in Swedish Pharmacies to Identify Potential Drug-Related Problems-Effects of a National Intervention Focused on Reviewing Elderly Patients' Prescriptions. PHARMACY 2020; 8:pharmacy8030118. [PMID: 32668586 PMCID: PMC7558108 DOI: 10.3390/pharmacy8030118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 02/01/2023] Open
Abstract
In pharmacies in Sweden, a clinical decision support system called Electronic Expert Support (EES) is available to analyse patients' prescriptions for potential drug-related problems. A nationwide intervention was performed in 2018 among all Swedish pharmacy chains to increase the use of EES among patients 75 years or older. The aim of this research was to study the use of EES in connection with the national intervention in order to describe any effects of the intervention, to understand how pharmacists use EES and to identify any barriers and facilitators for the use of EES by pharmacists for elderly patients. Data on the number and categories of EES analyses, alerts, resolved alerts and active pharmacies was provided by the Swedish eHealth Agency. The effects of the intervention were analysed using interrupted time series regression. A web-based questionnaire comprising 20 questions was sent to 1500 pharmacists randomly selected from all pharmacies in Sweden. The study shows that pharmacists use and appreciate EES and that the national intervention had a clear effect during the week of the intervention and seems to have contributed to a faster increase in pharmacists' use of EES during the year to follow. The study also identified several issues or barriers for using EES.
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Affiliation(s)
- Tora Hammar
- The eHealth Institute, Department of Medicine and Optometry, Linnaeus University, 391 82 Kalmar, Sweden;
- Correspondence: ; Tel.: +46-480-497176
| | - Lina Hellström
- The eHealth Institute, Department of Medicine and Optometry, Linnaeus University, 391 82 Kalmar, Sweden;
- Pharmaceutical Department, Region Kalmar County, 391 85 Kalmar, Sweden
| | - Lisa Ericson
- The Swedish eHealth Agency, 391 29 Kalmar, Sweden;
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Casey AN, Islam MM, Schütze H, Parkinson A, Yen L, Shell A, Winbolt M, Brodaty H. GP awareness, practice, knowledge and confidence: evaluation of the first nation-wide dementia-focused continuing medical education program in Australia. BMC FAMILY PRACTICE 2020; 21:104. [PMID: 32522153 PMCID: PMC7285709 DOI: 10.1186/s12875-020-01178-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/28/2020] [Indexed: 01/04/2023]
Abstract
Background Dementia is under-diagnosed in primary care. Timely diagnosis and care management improve outcomes for patients and caregivers. This research evaluated the effectiveness of a nationwide Continuing Medical Education (CME) program to enhance dementia-related awareness, practice, knowledge and confidence of general practitioners (GPs) in Australia. Methods Data were collected from self-report surveys by GPs who participated in an accredited CME program face-to-face or online; program evaluations from GPs; and process evaluations from workshop facilitators. CME participants completed surveys at one or more time-points (pre-, post-program, six to 9 months follow-up) between 2015 and 2017. Paired samples t-test was used to determine difference in mean outcome scores (self-reported change in awareness, knowledge, confidence, practice) between time-points. Multivariable regression analyses were used to investigate associations between respondent characteristics and key variables. Qualitative feedback was analysed thematically. Results Of 1352 GPs who completed a survey at one or more time-points (pre: 1303; post: 1017; follow-up: 138), mean scores increased between pre-CME and post-program for awareness (Mpost-pre = 0.9, p < 0.0005), practice-related items (Mpost-pre = 1.3, p < 0.0005), knowledge (Mpost-pre = 2.2, p < 0.0005), confidence (Mpost-pre = 2.1, p < 0.0005). Significant increases were seen in all four outcomes for GPs who completed these surveys at both pre- and follow-up time-points. Male participants and those who had practised for five or more years showed greater change in knowledge and confidence. Age, years in practice, and education delivery method significantly predicted post-program knowledge and confidence. Most respondents who completed additional program evaluations (> 90%) rated the training as relevant to their practice. These participants, and facilitators who completed process evaluations, suggested adding more content addressing patient capacity and legal issues, locality-specific specialist and support services, case studies and videos to illustrate concepts. Conclusions The sustainability of change in key elements relating to health professionals’ dementia awareness, knowledge and confidence indicated that dementia CME programs may contribute to improving capacity to provide timely dementia diagnosis and management in general practice. Low follow-up response rates warrant cautious interpretation of results. Dementia CME should be adopted in other contexts and updated as more research becomes available.
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Affiliation(s)
- Anne-Nicole Casey
- Dementia Centre for Research Collaboration, University of New South Wales (UNSW) Sydney, AGSM Building, Sydney, NSW, 2052, Australia.,Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - M Mofizul Islam
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, 3086, Australia
| | - Heike Schütze
- School of Health and Society, University of Wollongong, Wollongong, NSW, 2522, Australia.,School of Public Health and Community Medicine, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - Anne Parkinson
- Department of Health Services Research & Policy, Research School of Population Health, Australian National University, Canberra, NSW, 2601, Australia
| | - Laurann Yen
- Department of Health Services Research & Policy, Research School of Population Health, Australian National University, Canberra, NSW, 2601, Australia
| | - Allan Shell
- Dementia Centre for Research Collaboration, University of New South Wales (UNSW) Sydney, AGSM Building, Sydney, NSW, 2052, Australia
| | - Margaret Winbolt
- Dementia Training Australia, La Trobe University, Melbourne, VIC, 3086, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration, University of New South Wales (UNSW) Sydney, AGSM Building, Sydney, NSW, 2052, Australia. .,Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, Sydney, NSW, 2052, Australia. .,Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, NSW, 2031, Australia.
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Pu J, Donovan FM, Ellingson K, Leroy G, Stone J, Bedrick E, Galgiani JN. Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization. Clin Infect Dis 2020; 73:e1587-e1593. [PMID: 32511677 DOI: 10.1093/cid/ciaa739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/04/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Coccidioidomycosis (CM) is common and important within endemic regions, requiring specific testing for diagnosis. Long delays in diagnosis have been ascribed to ambulatory clinicians. However, how their testing practices have impacted patient care has not been systematically unexplored. METHODS We analyzed practice patterns for CM diagnoses over 3 years within a large Arizona healthcare system, including diagnosis location, patient characteristics, and care-seeking patterns associated with missed diagnosis. RESULTS For 2043 CM diagnoses, 72.9% were made during hospital admission, 21.7% in ambulatory clinics, 3.2% in emergency units, and only 0.5% in urgent care units. A 40.6% subgroup of hospitalized patients required neither intensive care unit or hospital-requiring procedures, had a median length of stay of only 3 days, but still incurred both substantial costs ($27.0 million) and unnecessary antibiotic administrations. Prior to hospital diagnosis (median of 32 days), 45.1% of patients had 1 or more visits with symptoms consistent with CM. During those visits, 71.3% were not tested for CM. Diagnoses were delayed a median of 27 days. CONCLUSIONS Lack of testing for CM in ambulatory care settings within a region endemic for CM resulted in a large number of hospital admissions, attendant costs, and unneeded antibacterial drug use, much of which would otherwise be unnecessary. Improving this practice is challenging since many clinicians did not train where CM is common, resulting in significant inertia to change. Determining the best way to retrain clinicians to diagnose CM earlier is an opportunity to explore which strategies might be the most effective.
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Affiliation(s)
- Jie Pu
- Division of Data Analytics, Banner Health Corporation, Phoenix, Arizona, USA
| | - Fariba M Donovan
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Kate Ellingson
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - Gondy Leroy
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Management Information Systems, University of Arizona Eller College of Business, Tucson, Arizona, USA
| | - Jeff Stone
- Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Arizona Cancer Center, University of Arizona-Tucson, Tucson, Arizona, USA
| | - Edward Bedrick
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - John N Galgiani
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
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79
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Shrestha S, Sharma S, Bhasima R, Kunwor P, Adhikari B, Sapkota B. Impact of an educational intervention on pharmacovigilance knowledge and attitudes among health professionals in a Nepal cancer hospital. BMC MEDICAL EDUCATION 2020; 20:179. [PMID: 32493307 PMCID: PMC7268292 DOI: 10.1186/s12909-020-02084-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/21/2020] [Indexed: 05/24/2023]
Abstract
BACKGROUND Pharmacovigilance (PV) knowledge and attitudes among health care professionals (HCPs) directly affect the practice of PV and reporting of adverse drug reactions (ADRs) in a hospital. The main aim of the study was to assess the impact of an education intervention on the knowledge and attitude of HCPs attached to the regional PV center in an oncology based hospital of Nepal. METHODS A pre-post intervention questionnaire-based study was conducted amongst HCPs, i.e. nurses and pharmacists of an oncology based hospital of Nepal. A 21-item pretested PV questionnaire (twelve and four statements for assessing knowledge and attitude respectively) was used before and after an educational intervention among 89 HCPs working in the hospital. SPSS version 21.0 was used to analyze pre- and post-survey data with descriptive and inferential statistics. The knowledge and attitude scores before and after educational intervention were analyzed with Wilcoxon rank-sum test. RESULTS After the educational intervention, the mean score for knowledge about PV and ADR increased from [mean ± S.D] 6.90 ± 2.527 (pre-test) to 11.36 ± 1.189 (post-test, p < 0.001). There were significant improvements after an educational intervention in attitude from 1.80 ± 0.932 (pre-test) to 3.61 ± 0.556 (post-test, p < 0.001). Twenty-one (23.6%) of participants responded that they lacked the time to report ADR, while 12 (13.5%) replied that there was no remuneration for reporting ADR. Approximately 24% of them recommended frequent pharmacovigilance awareness programs via continuing medical education or other similar kinds of workshops for improvement of pharmacovigilance. CONCLUSION The preliminary findings of this study showed that knowledge and attitude scores were increased following an educational intervention. They also suggested that training on PV and ADR tends to have a positive impact on knowledge and attitude among nurses and pharmacists working at an oncology based hospital in Nepal.
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Affiliation(s)
- Sunil Shrestha
- Pharmacy, Nepal Cancer Hospital and Research Center, Harisidhhi, Lalitpur, Nepal.
| | - Sabina Sharma
- Pharmacy, Nepal Cancer Hospital and Research Center, Harisidhhi, Lalitpur, Nepal
| | - Ramesh Bhasima
- Pharmacy, Nepal Cancer Hospital and Research Center, Harisidhhi, Lalitpur, Nepal
| | - Puskar Kunwor
- Clinical Pharmacy Unit, Nepal Cancer Hospital and Research Center, Harisidhhi, Lalitpur, Nepal
| | - Baburam Adhikari
- Pharmacy, Nepal Cancer Hospital and Research Center, Harisidhhi, Lalitpur, Nepal
| | - Binaya Sapkota
- Department of Pharmaceutical Sciences, Nobel College, Affiliated to Pokhara University, Sinamangal, Kathmandu, Nepal
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80
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Møen KA, Kumar B, Igland J, Diaz E. Effect of an Intervention in General Practice to Increase the Participation of Immigrants in Cervical Cancer Screening: A Cluster Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201903. [PMID: 32236530 PMCID: PMC7113727 DOI: 10.1001/jamanetworkopen.2020.1903] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Immigrant women have lower participation in cervical cancer screening (CCS) programs. At the same time, some groups of immigrants have higher prevalence of cervical cancer. Targeted interventions are therefore necessary. OBJECTIVE To determine whether an intervention among general practitioners (GPs) could influence immigrant women's participation in the Norwegian CCS program. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized clinical trial using the 20 subdistricts of the Bergen, Norway, municipality as clusters. The clusters were matched in 10 pairs according to the number of immigrant women living in them and randomized thereafter. The intervention was implemented between January and June 2017 among urban, primary care, general practices in Bergen. Follow-up ended in January 2018. General practices belonging to the control areas continued treatment as usual. A total of 10 360 women who attended 73 general practices in the 20 subdistricts were included as participants. INTERVENTION The intervention consisted of 3 elements: an educational session for GPs at lunch describing the importance of CCS among immigrants and giving advice about how to invite them to participate, a mouse pad as a reminder, and a poster placed in waiting rooms. In the educational session, we elaborated the need for GPs to ask every immigrant woman about CCS, regardless of their reason for contacting their GP. MAIN OUTCOMES AND MEASURES The main outcome, screening status of immigrant women by January 1, 2018, was obtained from the Norwegian Cancer Registry. The effect of the intervention was measured as odds ratio (OR) for CCS status as of January 1, 2018, for the intervention group vs the control group, with 3 levels of adjustments: baseline CCS status at January 1, 2017 (model 1), additional adjustment for women's age, marital status, income level, and region of origin (model 2), and further adjustment for the GP's sex, age, and region of origin (model 3). Two subgroup analyses, screening status at baseline and women's country of origin, were conducted to assess whether these factors had any influence on the effect of the intervention. Data were analyzed as intention to treat. RESULTS A total of 10 360 immigrant women, 5227 (50.4%; mean [SD] age, 44.0 [12.0] years) in the intervention group and 5133 (49.6%; mean [SD] age, 44.5 [11.6] years) in the control group, belonging to 39 general practices in the intervention area and 34 in the control area, were included in the study. The proportion of immigrant women screened increased by 2.6% in the intervention group and 0.6% in the control group. After adjustment for screening status at baseline, women in the intervention group were more likely to have participated in CCS (OR, 1.24 [95% CI, 1.11-1.38]). This statistically significant effect remained unchanged after adjustment for women's characteristics (OR, 1.24 [95% CI, 1.11-1.38]) and was reduced, but still significant, after further adjustment for GP characteristics (OR, 1.19 [95% CI, 1.06-1.34]). In subgroup analyses, the intervention particularly increased participation among women who were not previously screened at baseline (OR, 1.35 [95% CI, 1.16-1.56]), and those from Poland, Pakistan, and Somalia (OR, 1.74 [95% CI, 1.17-2.61]) when adjusting for baseline screening status. CONCLUSIONS AND RELEVANCE Our intervention targeting general practices significantly increased CCS participation among immigrants, although the absolute effect size of 2% in the fully adjusted model was small. Engaging other primary health professionals such as midwives to perform CCS could further contribute to increasing participation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03155581.
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Affiliation(s)
- Kathy Ainul Møen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Unit for Migration and Health, Norwegian Institute of Public Health (FHI), Oslo, Norway
| | - Bernadette Kumar
- Unit for Migration and Health, Norwegian Institute of Public Health (FHI), Oslo, Norway
| | - Jannicke Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Esperanza Diaz
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Unit for Migration and Health, Norwegian Institute of Public Health (FHI), Oslo, Norway
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81
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Krawiec C, Gerard S, Iriana S, Berger R, Levi B. What We Can Learn From Failure: An EHR-Based Child Protection Alert System. CHILD MALTREATMENT 2020; 25:61-69. [PMID: 31137955 DOI: 10.1177/1077559519848845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This study aimed to evaluate the efficacy of a newly implemented Child Protection Alert System (CPAS) that utilizes triggering diagnoses to identify children who have been confirmed/strongly suspected as maltreated. We retrospectively reviewed electronic health records (EHRs) of 666 patients evaluated by our institution's child protection team between 2009 and 2014. We examined each EHR for the presence of a pop-up alert, a persistent text-based visual alert, and diagnoses denoting child maltreatment. Diagnostic accuracy of the CPAS for child maltreatment identification was assessed. Of 323 patients for whom child maltreatment was confirmed/strongly suspected, 21.7% (70/323) had a qualifying longitudinal diagnosis listed. The pop-up alert fired in 14% of cases (45/323) with a sensitivity and specificity of 13.9% (95% CI [10.4%, 18.2%]) and 100% (95% CI [98.9%, 100.0%]), respectively. The text-based visual alert displayed in 44 of 45 cases. The CPAS is a novel simple way to support clinical decision-making to identify and protect children at risk of (re)abuse. This study highlights multiple barriers that must be overcome to effectively design and implement a CPAS to protect at-risk children.
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Affiliation(s)
- Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Children's Hospital, Hershey, PA, USA
| | - Seth Gerard
- Emergency Medicine, York Hospital, York, PA, USA
| | - Sarah Iriana
- Department of Pediatrics, General Academic Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Rachel Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin Levi
- Department of Pediatrics, General Academic Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
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82
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Anderson K, Freeman C, Foster M, Scott I. GP-Led Deprescribing in Community-Living Older Australians: An Exploratory Controlled Trial. J Am Geriatr Soc 2019; 68:403-410. [PMID: 31792947 DOI: 10.1111/jgs.16273] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/05/2019] [Accepted: 10/30/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess feasibility, effectiveness, and safety of a multifaceted general practitioner (GP) led intervention to reduce potentially inappropriate polypharmacy in community-living older people. DESIGN Pragmatic, controlled, pre-post design. SETTING Five general practices in southeast Queensland, Australia. PARTICIPANTS Ten GPs from three practices, two pharmacists, and 78 patients comprised the intervention group, and 10 GPs from two practices and 67 patients comprised the usual care group. Patients were aged 65 years or older, receiving five or more regularly prescribed medicines, and capable of participating in telephone interviews in English. INTERVENTION A 5-hour interactive deprescribing training workshop for clinicians; an extended deprescribing consultation between GPs and enrolled patients, entailing a comprehensive review of their medicines using a standardized software template codesigned by GPs; and comprehensive medicine review by a pharmacist, at the GP's discretion. OUTCOME MEASURES Primary outcome was mean difference in number of regular medicines deprescribed (ie, ceased or dose reduced) per patient over an 18-week follow-up period. Medicine-specific and patient-reported outcomes, safety, and process measures were also evaluated. RESULTS At study completion, mean (SD) number of regular medicines deprescribed per patient was 0.99 (1.23) in the intervention group vs 0.43 (0.84) in the usual care group, equaling a mean difference of 0.55 (95% confidence interval = -0.90 to -0.21; P = .002). Crude totals showed 77 of 649 (11.9%) vs 29 of 571 (5.1%) regular medicines deprescribed in intervention and usual care groups, respectively (P < .001). Supplements, gastric acid suppressants, statins, oral hypoglycemics, and diuretics were medicine classes more frequently deprescribed. There were no statistically significant between-group differences in numbers of medicines commenced, self-reported unplanned hospitalizations, or worsened health-related quality of life. A subset of intervention patients reported greater certainty in the necessity and appropriateness of their medicines at study end. CONCLUSION The deprescribing intervention appears feasible, was modestly effective, and was not associated with any major safety events. J Am Geriatr Soc 68:403-410, 2020.
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Affiliation(s)
- Kristen Anderson
- Centre of Research Excellence in Quality and Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Christopher Freeman
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Michele Foster
- Centre of Research Excellence in Quality and Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
| | - Ian Scott
- Centre of Research Excellence in Quality and Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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83
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Bruno C, Pearson SA, Daniels B, Buckley NA, Schaffer A, Zoega H. Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia. BMJ Qual Saf 2019; 29:365-373. [PMID: 31641029 PMCID: PMC7241967 DOI: 10.1136/bmjqs-2019-009897] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary. OBJECTIVE To evaluate the impact of national education initiatives on reducing PPI use in Australia. DESIGN Population-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control. INTERVENTIONS A year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate. MEASUREMENTS We examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation. RESULTS We observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained -1.7% (95% CI: -2.7 to -0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation. CONCLUSION Our findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice.
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Affiliation(s)
- Claudia Bruno
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Benjamin Daniels
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Andrea Schaffer
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Helga Zoega
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine, Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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84
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Yeung SSY, Reijnierse EM, Trappenburg MC, Meskers CGM, Maier AB. Current knowledge and practice of Australian and New Zealand health-care professionals in sarcopenia diagnosis and treatment: Time to move forward! Australas J Ageing 2019; 39:e185-e193. [PMID: 31617296 PMCID: PMC7497106 DOI: 10.1111/ajag.12730] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 01/06/2023]
Abstract
Objectives To describe the current knowledge and practice of sarcopenia diagnosis and treatment among health‐care professionals before, directly after and 6 months after a professional development event on sarcopenia. Methods This longitudinal study included Australian and New Zealand health‐care professionals who completed questionnaires on knowledge, practice and barriers regarding sarcopenia before, directly after and 6 months after attending a professional development event on sarcopenia. Results A total of 250 professionals participated; 84 completed the 6‐month questionnaires. Before, directly after and at 6 months, respectively, 14.7%, 93.4% and 59.5% identified sarcopenia as a disease; 2.0%, 79.6% and 38.1% correctly answered the sex‐specific cut‐offs for low handgrip strength. Respectively, 12.0% and 14.3% reported to make sarcopenia diagnoses as part of their practice before and at 6 months. Conclusions Knowledge about sarcopenia is limited among health‐care professionals who attended a professional development event. Retention of knowledge remains a challenge to be addressed.
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Affiliation(s)
- Suey S Y Yeung
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marijke C Trappenburg
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Internal Medicine, Amstelland Hospital, Amstelveen, The Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
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85
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Pettersson A, Modin S, Hasson H, Krakau I. Feasibility of referral to a therapist for assessment of psychiatric problems in primary care - an interview study. BMC FAMILY PRACTICE 2019; 20:117. [PMID: 31426751 PMCID: PMC6700983 DOI: 10.1186/s12875-019-1007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/08/2019] [Indexed: 11/27/2022]
Abstract
Background Depression and anxiety disorders are common in primary care. Comorbidities are frequent, and the diagnoses can be difficult. The Mini-International Neuropsychiatric Interview (MINI) can be a support in the clinical examination of patients with complex problems. However, for family practitioners (FPs), time and perceptions about structured interviews can be barriers to the MINI. An inter-professional teamwork process where FPs refer a patient to a therapist for a MINI assessment represents one way in which to address the problem. The results are fed back to the FPs for diagnosis and treatment decisions. The purposes of this study were to explore if the process was feasible for FPs, patients and therapists in Swedish primary care, and to identify factors influencing the process, using the COM-B model. Methods FPs at two primary care centers (PHCC) in Stockholm were offered the opportunity to refer patients to in-house therapists. Semi-structured interviews or focus groups were conducted with 22 patients, 17 FPs and three therapists to capture their experiences and perceptions. Inductive content analysis for each group of participants was followed by triangulation across groups. Finally, the categories obtained were fitted to the components in the COM-B. Results Therapists at both PHCCs conducted the MINI. The intended process was adopted at one PHCC. At the second PHCC, the responsibilities for the diagnosis and treatment of patients referred were transferred to the therapist. The patients were satisfied, as they appreciated multi-professional examinations. The FPs’ competence in psychiatry, actual access to therapists, beliefs that the referrals saved the FPs time and effort, and established habits influenced whether patients were referred. Existing routines and professional expectations for work content influenced the degree of cooperation between the therapists and the FPs. Conclusions An inter-professional diagnostic process where FPs refer patients to a therapist for assessment and the results are fed back to the FPs can be feasible. Feasibility depends on access to a therapist, the perceptions of roles and competences among FPs and therapists, and strategies for supporting teamwork. Electronic supplementary material The online version of this article (10.1186/s12875-019-1007-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Agneta Pettersson
- Procome, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden. .,Swedish Agency for Health Technology Assessment and Social Assessment, SE-102 33, Stockholm, Sweden.
| | - Sonja Modin
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23 D2, SE-141 83, Huddinge, Sweden
| | - Henna Hasson
- Procome, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden.,Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
| | - Ingvar Krakau
- Department of Medicine Solna, Karolinska Institutet, Clinical Epidemiology Unit T2, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
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86
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Kunstler BE, Lennox A, Bragge P. Changing prescribing behaviours with educational outreach: an overview of evidence and practice. BMC MEDICAL EDUCATION 2019; 19:311. [PMID: 31412928 PMCID: PMC6693161 DOI: 10.1186/s12909-019-1735-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/26/2019] [Indexed: 05/28/2023]
Abstract
BACKGROUND General practitioners (GPs), or family practitioners, are tasked with prescribing medications that can be harmful to the community if they are inappropriately prescribed or used (e.g. opioids). Educational programs, such as educational outreach (EO), are designed to change the behaviour of health professionals. The purpose of this study was to identify the efficacy of EO programs at changing the prescribing behaviour of GPs. METHODS This study included an evidence and practice review, comprising a rapid review supplemented by interviews with people who are familiar with EO implementation for regulation purposes. Seven databases were searched using terms related to health professionals and prescribing. Systematic and narrative reviews published in English after 2007 were included. Non-statistical analysis was used to report intervention efficacy. Three government representatives participated in semi-structured interviews to aid in understanding the relevance of review findings to the Victorian context. Interviews were transcribed verbatim and thematically analysed for emerging themes. RESULTS Fourteen reviews were identified for the evidence review. Isolated (e.g. EO program delivered by itself) and multifaceted (e.g. EO program supplemented by other interventions) programs were found to change prescribing behaviours. However, limited evidence suggests that EO can successfully change prescribing behaviours specific to GPs. Isolated EO can successfully change health professional prescribing behaviours, although cheaper alternatives such as letters might be just as effective. Multifaceted EO can also successfully change health professional prescribing behaviours, especially in older adults, but it remains unclear as to what combination of interventions works best. Success factors for EO reported by government representatives included programs having practical rather than didactic foci; making EO compulsory; focussing EO on preventing adverse events; using monetary or professional development incentives; and in-person delivery. CONCLUSIONS Educational outreach can successfully change prescribing behaviours but evidence specific to GPs is lacking. Key characteristics of EO that could optimise success include ensuring the EO program is tailored, involves practical learning and uses incentives that are meaningful to clinicians.
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Affiliation(s)
- Breanne E. Kunstler
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
| | - Alyse Lennox
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
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Cochran G, Cole ES, Warwick J, Donohue JM, Gordon AJ, Gellad WF, Bear T, Kelley D, DiDomenico E, Pringle J. Rural access to MAT in Pennsylvania (RAMP): a hybrid implementation study protocol for medication assisted treatment adoption among rural primary care providers. Addict Sci Clin Pract 2019; 14:25. [PMID: 31366408 PMCID: PMC6670171 DOI: 10.1186/s13722-019-0154-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/04/2019] [Indexed: 01/03/2023] Open
Abstract
Background The continued escalation of opioid use disorder (OUD) calls for heightened vigilance to implement evidence-based care across the US. Rural care providers and patients have limited resources, and a number of barriers exist that can impede necessary OUD treatment services. This paper reports the design and protocol of an implementation study seeking to advance availability of medication assisted treatment (MAT) for OUD in rural Pennsylvania counties for patients insured by Medicaid in primary care settings. Methods This project was a hybrid implementation study. Within a chronic care model paradigm, we employed the Framework for Systems Transformation to implement the American Society for Addiction Medicine care model for the use of medications in the treatment of OUD. In partnership with state leadership, Medicaid managed care organizations, local care management professionals, the Universities of Pittsburgh and Utah, primary care providers (PCP), and patients; the project team worked within 23 rural Pennsylvania counties to engage, recruit, train, and collaborate to implement the OUD service model in PCP practices from 2016 to 2019. Formative measures included practice-level metrics to monitor project implementation, and outcome measures involved employing Medicaid claims and encounter data to assess changes in provider/patient-level OUD-related metrics, such as MAT provider supply, prevalence of OUD, and MAT utilization. Descriptive statistics and repeated measures regression analyses were used to assess changes across the study period. Discussion There is an urgent need in the US to expand access to high quality, evidence-based OUD treatment—particularly in rural areas where capacity is limited for service delivery in order to improve patient health and protect lives. Importantly, this project leverages multiple partners to implement a theory- and practice-driven model of care for OUD. Results of this study will provide needed evidence in the field for appropriate methods for implementing MAT among a large number of rural primary care providers.
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Affiliation(s)
- Gerald Cochran
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, UT, 84132, USA.
| | - Evan S Cole
- University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Jack Warwick
- University of Pittsburgh Program Evaluation Research Unit, 5631 Baum Blvd, Pittsburgh, PA, 15206, USA
| | - Julie M Donohue
- University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, UT, 84132, USA
| | - Walid F Gellad
- University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Todd Bear
- University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - David Kelley
- Pennsylvania Department of Human Services, 625 Forster St, Harrisburg, PA, 17120, USA
| | - Ellen DiDomenico
- Pennsylvania Department of Human Services, 625 Forster St, Harrisburg, PA, 17120, USA
| | - Jan Pringle
- University of Pittsburgh Program Evaluation Research Unit, 5631 Baum Blvd, Pittsburgh, PA, 15206, USA.,University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, USA
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Brookes O, Brown C, Tarrant C, Archer J, Buckley D, Buckley LM, Clement I, Evison F, Gao Smith F, Gibbins C, Hayton E, Jones J, Lilford R, Mullhi R, Packer G, Perkins G, Shelton J, Snelson C, Sullivan P, Vlaev I, Wolstenholme D, Wright SE, Bion J. Patient experience and reflective learning (PEARL): a mixed methods protocol for staff insight development in acute and intensive care medicine in the UK. BMJ Open 2019; 9:e030679. [PMID: 31345985 PMCID: PMC6661565 DOI: 10.1136/bmjopen-2019-030679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/19/2019] [Accepted: 06/25/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Patient and staff experiences are strongly influenced by attitudes and behaviours, and provide important insights into care quality. Patient and staff feedback could be used more effectively to enhance behaviours and improve care through systematic integration with techniques for reflective learning. We aim to develop a reflective learning framework and toolkit for healthcare staff to improve patient, family and staff experience. METHODS & ANALYSIS Local project teams including staff and patients from the acute medical units (AMUs) and intensive care units (ICUs) of three National Health Service trusts will implement two experience surveys derived from existing instruments: a continuous patient and relative survey and an annual staff survey. Survey data will be supplemented by ethnographic interviews and observations in the workplace to evaluate barriers to and facilitators of reflective learning. Using facilitated iterative co-design, local project teams will supplement survey data with their experiences of healthcare to identify events, actions, activities and interventions which promote personal insight and empathy through reflective learning. Outputs will be collated by the central project team to develop a reflective learning framework and toolkit which will be fed back to the local groups for review, refinement and piloting. The development process will be mapped to a conceptual theory of reflective learning which combines psychological and pedagogical theories of learning, alongside theories of behaviour change based on capability, opportunity and motivation influencing behaviour. The output will be a locally-adaptable workplace-based toolkit providing guidance on using reflective learning to incorporate patient and staff experience in routine clinical activities. ETHICS & DISSEMINATION The PEARL project has received ethics approval from the London Brent Research Ethics Committee (REC Ref 16/LO/224). We propose a national cluster randomised step-wedge trial of the toolkit developed for large-scale evaluation of impact on patient outcomes.
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Affiliation(s)
- Olivia Brookes
- Research, Development & Innovation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Celia Brown
- Warwick Medical School (WMS), The University of Warwick, Warwick, UK
| | | | - Julian Archer
- Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
- Peninsula College of Medicine and Dentistry, Plymouth, UK
| | | | | | - Ian Clement
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Felicity Evison
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Fang Gao Smith
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Chris Gibbins
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Emma Hayton
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Richard Lilford
- Division of Health and Population Sciences, University of Warwick, Coventry, UK
| | - Randeep Mullhi
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Greg Packer
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin Perkins
- Clinical Trials Unit, University of Warwick, Birmingham, UK
| | - Jonathan Shelton
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | | | - Ivo Vlaev
- Warwick Business School, Coventry, UK
| | | | - Stephen E Wright
- Anaesthesia, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Julian Bion
- Intensive Care Medicine, University of Birmingham, Birmingham, UK
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89
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Kovacs E, Wang X, Strobl R, Grill E. Economic evaluation of guideline implementation in primary care: a systematic review. Int J Qual Health Care 2019; 32:1-11. [DOI: 10.1093/intqhc/mzz059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/29/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Purpose
To review the economic evaluation of the guideline implementation in primary care.
Data sources
Medline and Embase.
Study selection
Electronic search was conducted on April 1, 2019, focusing on studies published in the previous ten years in developed countries about guidelines of non-communicable diseases of adult (≥18 years) population, the interventions targeting the primary care provider. Data extraction was performed by two independent researchers using a Microsoft Access based form.
Results of data synthesis
Among the 1338 studies assessed by title or abstract, 212 qualified for full text reading. From the final 39 clinically eligible studies, 14 reported economic evaluation. Cost consequences analysis, presented in four studies, provided limited information. Cost-benefit analysis was reported in five studies. Patient mediated intervention, and outreach visit applied in two studies showed no saving. Audit resulted significant savings in lipid lowering medication. Audit plus financial intervention was estimated to reduce referrals into secondary care. Analysis of incremental cost-effectiveness ratios was applied in four studies. Educational meeting evaluated in a simulated practice was cost-effective. Educational meeting extended with motivational interview showed no improvement; likewise two studies of multifaceted intervention. Cost-utility analysis of educational meeting supported with other educational materials showed unfavourable outcome.
Conclusion
Only a minor proportion of studies reporting clinical effectiveness of guideline implementation interventions included any type of economic evaluation. Rigorous and standardized cost-effectiveness analysis would be required, supporting decision-making between simple and multifaceted interventions through comparability.
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Affiliation(s)
- Eva Kovacs
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
- German Center for Vertigo and Balance Disorders, Faculty of Medicine, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - Xiaoting Wang
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - Ralf Strobl
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
- German Center for Vertigo and Balance Disorders, Faculty of Medicine, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
- Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
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90
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Improving treatment of patients with inflammatory bowel diseases: a controlled trial of a multifaceted intervention in two German cities. Int J Colorectal Dis 2019; 34:1233-1240. [PMID: 31127363 DOI: 10.1007/s00384-019-03317-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Many recommendations from clinical practice guidelines are not implemented. We aimed to develop and evaluate a multifaceted strategy for the implementation of guidelines for Crohn's disease (CD) and ulcerative colitis (UC). METHODS In the intervention region (Berlin, Germany), a continuing medical education course was held, brief guidelines for practice were distributed to all family physicians and gastroenterologists, and patient guidelines were distributed to all surveyed patients. Educational outreach visits with local opinion leaders were also conducted. No specific interventions were performed in the control region (Hamburg, Germany). Prior to the intervention and 1 year later, 1900 members of three statutory sickness funds were asked about their treatment according to guidelines with (1) long-term aminosalicylates and (2) immunosuppressants, (3) whether they took long-term glucocorticoids for maintenance of remission, (4) if they smoked, in CD patients, and (5) about the surveillance colonoscopies, in UC patients. RESULTS Response rate after implementation was 20.1%. Responders differed between intervention and control region by age and by distribution between patients with UC or CD. After 1 year, more patients were treated according to clinical practice guidelines in the control region than in the intervention region. More patients in the intervention region took immunosuppressants after 1 year, and fewer had a surveillance colonoscopy. However, no before-after comparison was statistically significant. CONCLUSIONS This implementation strategy of UC and CD guidelines did not result in a statistically significant effect. Future implementation of guidelines for inflammatory bowel disease might need thorough evaluation of barriers and the support of theory-based concepts.
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91
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Fallucco EM, James L, Smotherman C, Greco P. Impact of Experiential Training With Standardized Patients on Screening and Diagnosis of Adolescent Depression in Primary Care. J Adolesc Health 2019; 65:57-62. [PMID: 30879884 DOI: 10.1016/j.jadohealth.2018.12.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/21/2018] [Accepted: 12/26/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Primary care providers (PCPs) report inadequate training in depression care. The objective of this study was to examine the long-term impact of PCP training with standardized patients on screening and diagnosis of adolescent depression in primary care. METHODS A retrospective review of electronic medical and billing records for adolescent (aged 12-18 years) well-visits assessed the frequency of screening and new diagnoses of depression. Twenty-five PCPs participated in training. The study included all adolescent well-visits in the 12 months before and after PCP training. Adolescents with a previous diagnosis of depression were excluded from the sample. Univariate and multivariable analyses were used to assess associations with screening. Odds ratios were used to describe the magnitude of associations. RESULTS The analysis included 7,108 well-visits for adolescents (mean age 14.5 years, standard deviation 1.7 years; gender: 52% male; race: 65% white, 13% black, 22% other races; ethnicity: 25% Hispanic; insurance: 67% commercial). Depression screening rate increased significantly after training from 51% to 80% of adolescents seen at well-visits (adjusted odds ratio 40.8, 95% confidence interval 32.6-51.0, p < .0001). Although the likelihood of being screened for depression increased post-training, there was variation based on patient's insurance. A significantly greater percentage of adolescents were newly diagnosed with depression after training (2.22% vs. .89%, p < .0001). CONCLUSIONS PCPs who participated in experiential training using standardized patients were more likely to screen for and diagnose adolescent depression in the 12 months after training. Future studies are needed to examine the effects of PCP training on patient outcomes.
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Affiliation(s)
- Elise M Fallucco
- Department of Psychiatry, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida.
| | - Lauren James
- Department of Psychiatry, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Peggy Greco
- Division of Psychology, Department of Pediatrics, Nemours Children's Healthcare System, Jacksonville, Florida
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92
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Bernardes CM, Ratnasekera IU, Kwon JH, Somasundaram S, Mitchell G, Shahid S, Meiklejohn J, O'Beirne J, Valery PC, Powell E. Contemporary Educational Interventions for General Practitioners (GPs) in Primary Care Settings in Australia: A Systematic Literature Review. Front Public Health 2019; 7:176. [PMID: 31316961 PMCID: PMC6609323 DOI: 10.3389/fpubh.2019.00176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/12/2019] [Indexed: 11/26/2022] Open
Abstract
Background: The primary purpose of educational interventions is to optimize the clinical management of patients. General practitioners (GPs) play a major role in the detection and management of diseases. This systematic literature review will describe the type and outcomes of educational interventions designed for general practitioners (GPs) in the Australian context. Methods: PubMed, CINHAL, and Scopus databases were systematically searched for studies on educational interventions conducted for GPs in Australia during 1st January 2008 to 11th June 2018. Data collected on the methodology of the interventions, GPs satisfaction regarding the educational intervention, changes in knowledge, confidence, skills and clinical behavior of the GPs. We also assessed whether the acquired clinical competencies had an impact on organizational change and on patient health. Results: Thirteen publications were included in this review. The methods with which educational interventions were developed and implemented varied substantially and rigorous evaluation was generally lacking particularly in detailing the outcomes. The reported GP response rate varied between 2 and 96% across studies, depending upon the method of recruitment, the type of intervention and the study setting (rural vs. urban). The most effective recruitment strategy was a combination of initial contact coupled with a visit to GP practices. Nine of the studies reviewed reported improvement in at least one outcome measure: gaining knowledge, improving skills or change in clinical behavior which was translated into clinical practice. In the 3 pre- and post-intervention analysis studies, 90–100% of the participating GPs reported improvement in their knowledge and attitudes. Conclusion: Education interventions for GPs in Australia had low response (recruitment) and retention (GPs that participated in follow-ups) rates, even when financial benefits or CPD points were used as incentives. Higher GP response rates were achieved through multiple recruitment strategies. Multifaceted interventions were more likely to achieve the primary outcome by improving knowledge, skills or changing practice, but the effect was often modest. Inconsistent results were reported in studies involving the use of multiple contact methods within an intervention and conducting online interventions.
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Affiliation(s)
| | | | - Joo Hyun Kwon
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sivagowri Somasundaram
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Geoff Mitchell
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Shaouli Shahid
- Centre for Aboriginal Studies, Curtin University, Perth, WA, Australia
| | | | - James O'Beirne
- Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia
| | - Patricia Casarolli Valery
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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93
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Hughes MC, Baker TA, Kim H, Valdes EG. Health behaviors and related disparities of insured adults with a health care provider in the United States, 2015-2016. Prev Med 2019; 120:42-49. [PMID: 30639668 DOI: 10.1016/j.ypmed.2019.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 12/31/2018] [Accepted: 01/08/2019] [Indexed: 11/26/2022]
Abstract
Health care providers are in a unique position to address patients' health behaviors and social determinants of health, factors like income and social support that can significantly impact health. There is a need to better understand the risk behaviors of a population that providers may counsel (i.e., those who are insured and have a provider.) Using the 2015 and 2016 CDC's Behavioral Risk Factor Surveillance System, we examine the prevalence of health behaviors and the existence of disparities in health behaviors based on social determinants among American adults. Our sample included noninstitutionalized adults aged 18 to 64 years, in the U.S. (N > 300,000). We used multivariate logistic regression analysis to assess the independent effects of income, education, sex, race, and metropolitan status on nine key health behaviors. Among adults with insurance and a provider (n > 200,000): 1) rates of engaging in poor health behaviors ranged from 6.4% (heavy drinking) to 68.1% (being overweight or obese), 2) rural residence, lower income, and lower education were associated with decreased clinical preventive services, 3) lower income and lower education were associated with lifestyle-related risks, and 4) being black was associated with receiving more cancer screenings, no influenza vaccination, inadequate physical activity, and being overweight or obese. Insured adults, with a provider, are not meeting recommended guidelines for health behaviors. Significant disparities in health behaviors related to social factors exist among this group. Health care providers and organizations may find it helpful to consider these poor health behaviors and disparities when determining strategies to address SDOH.
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Affiliation(s)
- M Courtney Hughes
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA.
| | - Tamara A Baker
- Department of Psychology, University of Kansas, 454 Fraser Hall, Lawrence, KS 66045, USA; Gerontology Program, University of Kansas, 3091 Dole, Lawrence, KS 66045, USA.
| | - Hansol Kim
- Gerontology Program, University of Kansas, 3091 Dole, Lawrence, KS 66045, USA.
| | - Elise G Valdes
- Relias Institute, 111 Corning Road, Suite 250, Cary, NC 27518, USA.
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94
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Strasser R, Smith R, Yates P, Reid D, Katz B. Resuscitation planning on a subacute geriatric evaluation and management ward. Australas J Ageing 2019; 38:e114-e120. [DOI: 10.1111/ajag.12633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Rupert Strasser
- St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Roger Smith
- St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Paul Yates
- Austin Health Heidelberg Victoria Australia
| | - David Reid
- St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Benny Katz
- St Vincent's Hospital Melbourne Melbourne Victoria Australia
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White R, Hayes C, Boyes AW, Chiu S, Paul CL. General practitioners and management of chronic noncancer pain: a cross-sectional survey of influences on opioid deprescribing. J Pain Res 2019; 12:467-475. [PMID: 30774416 PMCID: PMC6348964 DOI: 10.2147/jpr.s168785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background General practitioners’ (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs’ beliefs about deprescribing, including their decisions to deprescribe different types of POAs. Aim To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing. Design and setting In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken. Methods A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone. Results A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples’ long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient. Conclusions Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.
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Affiliation(s)
- Ruth White
- Hunter Integrated Pain Service, Hunter New England Health, Newcastle, NSW, Australia, .,School of Medicine and Public Health, University of Newcastle, NSW, Australia,
| | - Chris Hayes
- Hunter Integrated Pain Service, Hunter New England Health, Newcastle, NSW, Australia,
| | - Allison W Boyes
- School of Medicine and Public Health, University of Newcastle, NSW, Australia, .,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Simon Chiu
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Christine L Paul
- School of Medicine and Public Health, University of Newcastle, NSW, Australia, .,Hunter Medical Research Institute, Newcastle, NSW, Australia
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Kempegowda P, Chandan JS, Coombs B, De Bray A, Jawahar N, James S, Ghosh S, Narendran P. Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study. BMJ Open Diabetes Res Care 2019; 7:e000695. [PMID: 31497304 PMCID: PMC6708258 DOI: 10.1136/bmjdrc-2019-000695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/25/2019] [Accepted: 07/08/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management. DESIGN The study was based on 'theory of change' concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome. SETTING This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country. PARTICIPANTS All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study. INTERVENTIONS Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study. MAIN OUTCOME MEASURES Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists. RESULTS There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration. CONCLUSION Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.
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Affiliation(s)
- Punith Kempegowda
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Benjamin Coombs
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anne De Bray
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Nitish Jawahar
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sunil James
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sandip Ghosh
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Parth Narendran
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, Pleshakov TS, McLachlan ID, Yamin CK, Elms AR, Iskin HR, Vemula R, Yealy DM, Ballard DW. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med 2018; 169:855-865. [PMID: 30422263 DOI: 10.7326/m18-1206] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. OBJECTIVE To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. DESIGN Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). SETTING All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). PATIENTS Adult ED patients with acute PE. INTERVENTION Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. MEASUREMENTS The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. RESULTS Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. LIMITATION Lack of random allocation. CONCLUSION Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. PRIMARY FUNDING SOURCE Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente Sacramento Medical Center, Sacramento, California (D.R.V.)
| | - Dustin G Mark
- The Permanente Medical Group, Kaiser Permanente Northern California, and Kaiser Permanente Oakland Medical Center, Oakland, California (D.G.M.)
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, and Kaiser Permanente South San Francisco Medical Center, South San Francisco, California (U.K.C.)
| | - Jie Huang
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Mary E Reed
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - James S Lin
- The Permanente Medical Group, Oakland, and Kaiser Permanente Santa Clara Medical Center, Sacramento, California (J.S.L.)
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Leandro Medical Center, Sacramento, California (M.V.K.)
| | | | - Dana R Sax
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Tamara S Pleshakov
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.S.P.)
| | - Ian D McLachlan
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Francisco Medical Center, San Francisco, California (I.D.M.)
| | - Cyrus K Yamin
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Andrew R Elms
- The Permanente Medical Group, Oakland, and Kaiser Permanente South Sacramento Medical Center, Sacramento, California (A.R.E.)
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan (H.R.I.)
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio (R.V.)
| | - Donald M Yealy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y.)
| | - Dustin W Ballard
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente San Rafael Medical Center, San Rafael, California (D.W.B.)
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Keyworth C, Hart J, Armitage CJ, Tully MP. What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review. BMC Med Inform Decis Mak 2018; 18:93. [PMID: 30404638 PMCID: PMC6223001 DOI: 10.1186/s12911-018-0661-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023] Open
Abstract
Background Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation. Methods A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation. Results Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions. Conclusions Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Keyworth
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.
| | - J Hart
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK
| | - C J Armitage
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - M P Tully
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PL, UK
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Egerton T, Nelligan RK, Setchell J, Atkins L, Bennell KL. General practitioners' views on managing knee osteoarthritis: a thematic analysis of factors influencing clinical practice guideline implementation in primary care. BMC Rheumatol 2018; 2:30. [PMID: 30886980 PMCID: PMC6390779 DOI: 10.1186/s41927-018-0037-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 09/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background Osteoarthritis (OA) is diagnosed and managed primarily by general practitioners (GPs). OA guidelines recommend using clinical criteria, without x-ray, for diagnosis, and advising strengthening exercise, aerobic activity and, if appropriate, weight loss as first-line treatments. These recommendations are often not implemented by GPs. To facilitate GP uptake of guidelines, greater understanding of GP practice behaviour is required. This qualitative study identified key factors influencing implementation of these recommendations in the primary-care setting. Methods Semi-structured interviews with eleven GPs were conducted, transcribed verbatim, coded by two independent researchers and analysed with an interpretive thematic approach using the COM-B model (Capability/Opportunity/Motivation-Behaviour) as a framework. Results Eleven themes were identified. Psychological capability themes: knowledge gaps, confidence to effectively manage OA, and skills to facilitate lifestyle change. Physical opportunity themes: system-related factors including time limitations, and patient resources. Social opportunity theme: influences from patients. Reflective motivation themes: GP's perceived role, and assumptions about people with knee OA. Automatic motivation themes: optimism, habit, and unease discussing weight. The findings demonstrated diverse and interacting influences on GPs' practice. Conclusion The identified themes provide insight into potential interventions to improve OA management in primary-care settings. Key suggestions include: improvements to OA clinical guidelines; targeting GP education to focus on identified knowledge gaps, confidence, and communication skills; development and implementation of new models of service delivery; and utilising positive social influences to facilitate best-practice behaviours. Complex, multimodal interventions that address multiple factors (both barriers and facilitators) are likely to be necessary.
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Affiliation(s)
- Thorlene Egerton
- 1Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, Australia
| | - Rachel K Nelligan
- 1Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, Australia
| | - Jenny Setchell
- 2School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Lou Atkins
- 3Centre for Behaviour Change, University College London, London, UK
| | - Kim L Bennell
- 1Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, Australia
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