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Kegler MC, Rana S, Vandenberg AE, Hastings SN, Hwang U, Eucker SA, Vaughan CP. Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments. FRONTIERS IN HEALTH SERVICES 2022; 2:1053489. [PMID: 36925898 PMCID: PMC10012623 DOI: 10.3389/frhs.2022.1053489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
Background Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome. Materials and methods Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation. Results Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only. Discussion Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation. Conclusion This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.
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Affiliation(s)
- Michelle C. Kegler
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Shaheen Rana
- School of Medicine, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | | | - Ula Hwang
- Yale University School of Medicine, New Haven, CT, United States
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Würdemann FS, Voeten SC, Wilschut JA, Schipper IB, Hegeman JH. Data-driven development of the nationwide hip fracture registry in the Netherlands. Arch Osteoporos 2022; 18:2. [PMID: 36464755 PMCID: PMC9719884 DOI: 10.1007/s11657-022-01160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/31/2022] [Indexed: 12/09/2022]
Abstract
Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators. PURPOSE Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA). METHODS An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made. RESULTS In 4.904 analyzed patients, three tested variables had significant associations (p < 0.01) with outcomes: polypharmacy with complications (aOR 1.34), serum hemoglobin at admittance with complications (aOR 0.63) and mortality (aOR for 30-day mortality 0.78), and a set of questions screening for risk of delirium with complications in general (aOR 1.55), e.g., delirium (aOR 2.98), and decreased functional scores at three months (aOR 1.98). CONCLUSION This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.
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Affiliation(s)
- Franka S Würdemann
- Department of Traumasurgery, Leiden University Medical Center, Leiden, The Netherlands.
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands.
| | - Stijn C Voeten
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands
| | - Janneke A Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands
| | - Inger B Schipper
- Department of Traumasurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Johannes H Hegeman
- Department of Traumasurgery, Ziekenhuisgroep Twente, Almelo, Hengelo, The Netherlands
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Quigley M, Earnest A, Andrikopoulos S, Wischer N, Green S, Zoungas S. ANDA-Evaluating Facilitated Feedback Enhancement - a Cluster randomised Trial (ANDA-EFFECT): protocol for a cluster randomised trial of audit feedback augmented with education and support, compared to feedback alone, on acceptability, utility and health outcomes in diabetes centres in Australia. Trials 2022; 23:976. [PMID: 36471424 PMCID: PMC9720980 DOI: 10.1186/s13063-022-06910-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND People living with diabetes must manage a range of factors for optimal control of glycaemia and to minimise the risk of diabetes-related complications. Diabetes practitioners are expected to follow guidelines for the key process of care and clinical outcomes, to help people living with diabetes achieve clinical targets. In Australia, the performance of diabetes centres against guidelines is evaluated by the Australian National Diabetes Audit, an annual clinical audit and feedback activity. Previous work has identified areas for improvement in the feedback provided to participating diabetes centres and suggested additional educational and support resources to assist in using audit feedback for the development of quality improvement activities. This cluster randomised trial will test the acceptability, utility and impact on selected clinical outcomes of the developed study intervention (audit feedback and a tailored educational and peer support cointervention). METHODS Two-armed cluster randomised trial with Australian Diabetes Centres that participated in the Australian National Diabetes Audit in 2021 as the clusters, stratified by location and type of centre. We aim to recruit 35 diabetes centres in each arm. Both the intervention and control arms will receive an augmented feedback report, accompanied by a partially pre-populated slide deck. In addition, the intervention arm will receive a tailored theory-based intervention designed to address identified, modifiable barriers to utilising and implementing the recommendations from diabetes audit feedback. The co-primary outcomes are (1) HbA1c at the patient level, measured at 6 months after delivery of the intervention, and (2) the acceptability and utility of the augmented feedback and cointerventions at the practitioner level, measured at 3 months after delivery of the intervention. DISCUSSION This trial aims to test the effects of systematic development and implementation of theory and evidence-informed changes to the audit feedback delivered to diabetes centres participating in an established national clinical diabetes audit. Potential benefits of improved audit feedback include more optimal engagement with the feedback by end clinical users which, ultimately, may lead to improvements in care for people living with diabetes. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTRN12621000765820. Prospectively registered on June 21, 2021.
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Affiliation(s)
- Matthew Quigley
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004 Australia
| | - Arul Earnest
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004 Australia
| | - Sofianos Andrikopoulos
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004 Australia ,grid.470804.f0000 0004 5898 9456Australian Diabetes Society, Sydney, NSW 2000 Australia
| | - Natalie Wischer
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004 Australia ,National Association of Diabetes Centres, Sydney, NSW 2000 Australia
| | - Sally Green
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004 Australia
| | - Sophia Zoungas
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004 Australia ,grid.419789.a0000 0000 9295 3933Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC 3168 Australia
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Ramírez-Morera A, Tristán M, Salazar-Vargas J, Rivera-Chavarría AL. Effects of evidence-based clinical practice guidelines for breast cancer in health care quality improvements. A second systematic review. F1000Res 2022; 11:1213. [PMID: 36619604 PMCID: PMC9780606 DOI: 10.12688/f1000research.126126.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Traditionally, EB-CPGs have been believed to mainly improve the quality and consistency of health care, but this claim must be conclusively proven. We used the Donabedian three-dimensional model (structure, process, and patient outcomes) to assess improvements in the quality of medical care derived from implementing EB-CPGs. This study corresponds to the second systematic review carried out as a series of studies on different clinical issues that aim to evaluate the effectiveness of the application of the EB-CPG for improving the quality of care. Methods: We followed the methods described by the Cochrane Handbook and presented a descriptive analysis because of the high heterogeneity found across the included studies. We searched the Cochrane Central Register of Controlled Trials, PubMed, and EBSCO Host databases, as well as the grey literature, between 1990 and April 2021. No language restrictions were applied. Only randomised clinical trials (RCTs) were selected. Results: Of the total of 364 interventions included in the eleven RCTs evaluated, 11 (3%) were related to healthcare structure, 51 (14%) to the healthcare delivery process and 302 (83%) to patient outcomes. Regarding the impact of using the EB-CPGs, in 303 interventions (83%), there were no significant differences between the control and experimental groups. In 4 interventions (1%), the result favoured the control and intervention groups in 57 of the interventions (16%). Conclusions: Our study showed that EB-CPGs slightly enhanced the quality of health care in the three dimensions described by Donabedian. Future RCTs should improve their design and methodological rigour by considering the certainty of the evidence supporting the EB-CPGs recommendations. In that context, broader analyses could be performed, having more concise hypotheses for further research. Registration: PROSPERO CRD42020205594.
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Affiliation(s)
- Anggie Ramírez-Morera
- Cochrane Central America & Caribbean Spanish, IHCAI Foundation, San José, San José, 10101, Costa Rica,Universitat Autònoma de Barcelona, Barcelona, Catalunya, 08041, Spain,Caja Costarricense de Seguro Social, San José, San José, 10105, Costa Rica,
| | - Mario Tristán
- Cochrane Central America & Caribbean Spanish, IHCAI Foundation, San José, San José, 10101, Costa Rica
| | | | - Ana Leonor Rivera-Chavarría
- Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud, Tres Ríos, Cartago, 42250, Costa Rica
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Xie N, Xie H, Tang W. Baseline assessment of enhanced recovery after pediatric surgery in mainland China. Pediatr Surg Int 2022; 39:32. [PMID: 36459300 DOI: 10.1007/s00383-022-05315-8] [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: 11/19/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China. METHODS We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD). RESULTS A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%). CONCLUSIONS The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.
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Affiliation(s)
- Nan Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China
| | - Hua Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China.
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Cadilhac DA, Marion V, Andrew NE, Breen SJ, Grabsch B, Purvis T, Morrison JL, Lannin NA, Grimley RS, Middleton S, Kilkenny MF. A Stepped-Wedge Cluster-Randomized Trial to Improve Adherence to Evidence-Based Practices for Acute Stroke Management. Jt Comm J Qual Patient Saf 2022; 48:653-664. [PMID: 36307360 DOI: 10.1016/j.jcjq.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data. METHODS STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change champions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and individual indicators (secondary outcome). Patient survival and disability 90-180 days after stroke were also compared. RESULTS Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years; 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years; 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals' action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05-1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50-2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05-1.53). Patient outcomes were unchanged. CONCLUSION External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care.
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Tilson JK, Martinez CA, MacDowell S, D’Silva LJ, Howard R, Roth HR, Skop KM, Dannenbaum E, Farrell L. Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series. BMC Health Serv Res 2022; 22:1462. [PMID: 36456945 PMCID: PMC9714412 DOI: 10.1186/s12913-022-08796-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 11/05/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND When a new guideline is published there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings. METHODS Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change. RESULTS Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location. CONCLUSIONS The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model. TRIAL REGISTRATION This study does not report the results of a health care intervention on human participants.
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Affiliation(s)
- Julie K. Tilson
- grid.42505.360000 0001 2156 6853Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California USA
| | - Clarisa A. Martinez
- grid.42505.360000 0001 2156 6853Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California USA
| | - Sara MacDowell
- grid.417320.30000 0000 9612 8770Physical Therapy, Hearing and Balance Center, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana USA
| | - Linda J. D’Silva
- grid.412016.00000 0001 2177 6375Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, Kansas USA
| | - Robbin Howard
- grid.42505.360000 0001 2156 6853Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California USA
| | - Heidi R. Roth
- grid.16753.360000 0001 2299 3507Northwestern University School of Physical Therapy and Human Movement Sciences and Shirley Ryan AbilityLab, Chicago, IL USA
| | - Karen M. Skop
- grid.170693.a0000 0001 2353 285XPhysical Medicine and Rehabilitation Services, Department of Physical Therapy, James A. Haley Veterans’ Hospital, Morsani College of Medicine, University of South Florida, School of Physical Therapy, Tampa, FL USA
| | - Elizabeth Dannenbaum
- grid.414993.20000 0000 8928 6420Vestibular Program, Jewish Rehabilitation Hospital Foundation, Laval, Quebec Canada
| | - Lisa Farrell
- Symmetry Alliance, LLC, Fort Lauderdale, Florida USA
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Roche KF, Morrissey EC, Cunningham J, Molloy GJ. The use of postal audit and feedback among Irish General Practitioners for the self – management of antimicrobial prescribing: a qualitative study. BMC PRIMARY CARE 2022; 23:86. [PMID: 35436863 PMCID: PMC9014781 DOI: 10.1186/s12875-022-01695-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
Abstract
Objective Inappropriate use of antibiotics has been acknowledged as a significant contributor to the proliferation of antimicrobial resistance worldwide. Physician prescribing of antibiotics has been identified as a factor in the inappropriate use of antibiotics. One methodology that is used in an attempt to alter physician prescribing behaviours is audit and feedback. This study aimed to explore the perceptions of Irish General Practitioners (GPs) towards the national introduction of postal feedback on their antibiotic prescribing behaviours beginning in 2019. Design A qualitative descriptive methodology was used. Semi–structured interviews were conducted with GPs in receipt of postal audit and feedback. Method GPs working in Ireland and in receipt of postal audit and feedback on their antibiotic prescribing behaviours participated in phone-based interviews. The interviews were recorded and transcribed verbatim. The collected data was then analysed using an inductive thematic analysis. Results Twelve GPs participated in the study (female = 5). Three themes were identified from the analysis. The themes identified were the reliability and validity of the feedback received, feedback on antibiotic prescribing is useful but limited and feedback needs to be easily digestible. Conclusion While the postal audit and feedback were broadly welcomed by the participants, the themes identified a perceived limitation in the quality of the feedback data, the perception of a likely low public health impact of the feedback and difficulties with efficiently processing the audit and feedback information. These findings can help refine future audit and feedback interventions on antibiotic prescribing. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01695-x.
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Singer A, Kosowan L, Abrams EM, Katz A, Lix L, Leong K, Paige A. Implementing an audit and feedback cycle to improve adherence to the Choosing Wisely Canada recommendations: clustered randomized trail. BMC PRIMARY CARE 2022; 23:302. [PMID: 36435746 PMCID: PMC9701433 DOI: 10.1186/s12875-022-01912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Audit and Feedback (A&F), a strategy aimed at promoting modified practice through performance feedback, is a method to change provider behaviour and reduce unnecessary medical services. This study aims to assess the use of A&F to reduce antibiotic prescribing for viral infections and antipsychotic prescribing to patients with dementia. METHODS Clustered randomized trial of 239 primary care providers in Manitoba, Canada, participating in the Manitoba Primary Care Research Network. Forty-six practices were randomly assigned to one of three groups: control group, intervention 1 (recommendations summary), intervention 2 (recommendations summary and personalized feedback). We assessed prescribing rates prior to the intervention (2014/15), during and immediately after the intervention (2016/17) and following the intervention (2018/19). Physician characteristics were assessed. RESULTS Between 2014/15-2016/17, 91.6% of providers in intervention group 1 and 95.9% of providers in intervention group 2 reduced their antibiotic and antipsychotic prescribing rate by ≥ 1 compared to the control group (77.6%) (p-value 0.0073). This reduction was maintained into 2018/19 at 91.4%. On multivariate regression alternatively funded providers had 2.4 × higher odds of reducing their antibiotic prescribing rate compared to fee-for-service providers. In quantile regression of providers with a reduction in antibiotic prescribing, alternatively funded (e.g. salaried or locum) providers compared to fee-for-service providers were significant at the 80th quantile. CONCLUSIONS Both A&F and recommendation summaries sent to providers by a trusted source reduced unnecessary prescriptions. Our findings support further scale up of efforts to engage with primary care practices to improve care with A&F. TRIAL REGISTRATION ClinicalTrials.gov NCT05385445, retrospectively registered, 23/05/2022.
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Affiliation(s)
- Alexander Singer
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Leanne Kosowan
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Alan Katz
- Departments of Community Health Science & Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Centre for Health Policy, Winnipeg, MB, Canada
| | - Lisa Lix
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Katrina Leong
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Allison Paige
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Lombardi G, Chipi E, Arenella D, Fiorani A, Frisoni GB, Linarello S, Montanucci C, Muscio C, Pacifico I, Pelizzari S, Perani D, Piras F, Rozzini L, Sorbi S, Spalletta G, Tagliavini F, Tiraboschi P, Parnetti L, Filippini G. Educational interventions to improve detection and management of cognitive decline in primary care-An Italian multicenter pragmatic study. Front Psychiatry 2022; 13:1050583. [PMID: 36506451 PMCID: PMC9731677 DOI: 10.3389/fpsyt.2022.1050583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Timely detection of cognitive decline in primary care is essential to promote an appropriate care pathway and enhance the benefits of interventions. We present the results of a study aimed to evaluate the effectiveness of an educational intervention addressed to Italian family physicians (FPs) to improve timely detection and management of cognitive decline. Materials and methods We conducted a pre-post study in six Italian health authorities (HAs) involving 254 FPs and 3,736 patients. We measured process and outcome indicators before the intervention (1 January 2014 to 31 December 2016) and after the intervention (1 January 2018 to 31 December 2019). One interactive face-to-face session workshop was delivered by local cognitive disorders and dementia specialists and FP advisors at each HA, in the period September 2017-December 2017. The session focused on key messages of the local Diagnostic and Therapeutic Care Pathway (DTCP) or regional guidelines: (a) the role of the FP for a timely suspicion of cognitive decline is fundamental; (b) when cognitive decline is suspected, the role of the FP is active in the diagnostic work-up; (c) FP's knowledge on pharmacological and non-pharmacological interventions is essential to improve the management of patients with cognitive decline. Results An overall improvement in diagnostic procedures and management of patients with cognitive decline by FPs after the intervention was observed. The number of visits per year performed by FPs increased, and the time interval between the first FP consultation and the diagnosis was optimized. Neuroleptic use significantly decreased, whereas the use of benzodiazepines remained steadily high. Non-pharmacological interventions, or use of support services, were underrepresented even in the post-intervention. Differences among the participating HAs were identified and discussed. Discussion Results from this study suggest the success of the educational intervention addressed to FPs in improving early detection and management of cognitive decline, highlighting the importance to continue medical education in this field. At the same time, further initiatives of care pathway dissemination and implementation should promote strategies to enhance interactions between primary and secondary care optimizing the collaboration between FPs and specialists.
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Affiliation(s)
| | - Elena Chipi
- Centre for Memory Disturbances, Section of Neurology, Lab of Clinical Neurochemistry, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | | | - Ambra Fiorani
- Laboratory of Neurology, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanni Battista Frisoni
- Laboratory of Epidemiology and Neuroimaging, IRCCS San Giovanni di Dio - Fatebenefratelli, Brescia, Italy
- Memory Clinic, Geneva University Hospitals, Geneva, Switzerland
| | | | - Chiara Montanucci
- Centre for Memory Disturbances, Section of Neurology, Lab of Clinical Neurochemistry, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Cristina Muscio
- ASST Bergamo Ovest - Azienda Socio Sanitaria Territoriale di Bergamo Ovest, Bergamo, Italy
| | - Irene Pacifico
- Laboratory of Neuropsychiatry, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Silvia Pelizzari
- Centro per i Disturbi Cognitivi e le Demenze, Spedali Civili di Brescia, Brescia, Italy
| | - Daniela Perani
- Division of Neuroscience, San Raffaele Scientific Institute, San Raffaele University, Milan, Italy
| | - Fabrizio Piras
- Laboratory of Neuropsychiatry, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Luca Rozzini
- Centro per i Disturbi Cognitivi e le Demenze, Spedali Civili di Brescia, Brescia, Italy
| | - Sandro Sorbi
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
- Section of Psychology - Department of Neuroscience, Psychology, Drug Research and Child’s Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Gianfranco Spalletta
- Laboratory of Neuropsychiatry, IRCCS Santa Lucia Foundation, Rome, Italy
- Division of Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | | | | | - Lucilla Parnetti
- Centre for Memory Disturbances, Section of Neurology, Lab of Clinical Neurochemistry, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Cranley LA, Lo TKT, Weeks LE, Hoben M, Ginsburg LR, Doupe M, Anderson RA, Wagg A, Boström AM, Estabrooks CA, Norton PG. Reporting unit context data to stakeholders in long-term care: a practical approach. Implement Sci Commun 2022; 3:120. [DOI: 10.1186/s43058-022-00369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
Abstract
Background
The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context.
Methods
We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis.
Results
Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method.
Conclusions
We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.
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Dempsey K, Ferguson C, Walczak A, Middleton S, Levi C, Morton RL, Boydell K, Campbell M, Cass A, Duff J, Elliott C, Geelhoed G, Jones A, Keech W, Leone V, Liew D, Linedale E, Mackinolty C, McFayden L, Norris S, Skouteris H, Story D, Tucker R, Wakerman J, Wallis L, Waterhouse T, Wiggers J. Which strategies support the effective use of clinical practice guidelines and clinical quality registry data to inform health service delivery? A systematic review. Syst Rev 2022; 11:237. [PMID: 36352475 PMCID: PMC9644489 DOI: 10.1186/s13643-022-02104-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Empirical evidence suggests data and insights from the clinical practice guidelines and clinical quality registries are not being fully utilised, leaving health service managers, clinicians and providers without clear guidance on how best to improve healthcare delivery. This lack of uptake of existing research knowledge represents low value to the healthcare system and needs to change. METHODS Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews) were systematically searched. Included studies were published between 2000 and 2020 reporting on the attributes, evidence usage and impact of clinical practice guidelines and clinical quality registries on health service delivery. RESULTS Twenty-six articles including one randomised controlled trial, eight before-and-after studies, eight case studies/reviews, five surveys and four interview studies, covering a wide range of medical conditions and conducted in the USA, Australia and Europe, were identified. Five complementary strategies were derived to maximise the likelihood of best practice health service delivery: (1) feedback and transparency, (2) intervention sustainability, (3) clinical practice guideline adherence, (4) productive partnerships and (5) whole-of-team approach. CONCLUSION These five strategies, used in context-relevant combinations, are most likely to support the application of existing high-quality data, adding value to health service delivery. The review highlighted the limitations of study design in opportunistic registry studies that do not produce clear, usable evidence to guide changes to health service implementation practices. Recommendations include exploration of innovative methodologies, improved coordination of national registries and the use of incentives to encourage guideline adherence and wider dissemination of strategies used by successful registries.
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Affiliation(s)
- Kathy Dempsey
- Faculty of Medicine and Health, NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, 2050, Australia.
| | | | - Adam Walczak
- Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), University of NSW, Kensington, Australia
| | - Sandy Middleton
- Nursing Research Unit, Australian Catholic University, Sydney, Australia
| | - Christopher Levi
- Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), University of NSW, Kensington, Australia
| | - Rachael L Morton
- Faculty of Medicine and Health, NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, 2050, Australia
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Payne RA, Blair PS, Caddick B, Chew-Graham CA, Dreischulte T, Duncan LJ, Guthrie B, Mann C, Parslow RM, Round J, Salisbury C, Turner KM, Turner NL, McCahon D. Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP): Protocol for a multicentre cluster randomised trial comparing a complex intervention for medication optimization against usual care. NIHR OPEN RESEARCH 2022; 2:54. [PMID: 37881305 PMCID: PMC10593356 DOI: 10.3310/nihropenres.13285.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 10/27/2023]
Abstract
Introduction Polypharmacy is increasingly common, and associated with undesirable consequences. Polypharmacy management necessitates balancing therapeutic benefits and risks, and varying clinical and patient priorities. Current guidance for managing polypharmacy is not supported by high quality evidence. The aim of the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial is to evaluate the effectiveness of an intervention to optimise medication use for patients with polypharmacy in a general practice setting. Methods This trial will use a multicentre, open-label, cluster-randomised controlled approach, with two parallel groups. Practices will be randomised to a complex intervention comprising structured medication review (including interprofessional GP/pharmacist treatment planning and patient-facing review) supported by performance feedback, financial incentivisation, clinician training and clinical informatics (intervention), or usual care (control). Patients with polypharmacy and triggering potentially inappropriate prescribing (PIP) indicators will be recruited in each practice using a computerised search of health records. 37 practices will recruit 50 patients, and review them over a 26-week intervention delivery period. The primary outcome is the mean number of PIP indicators triggered per patient at 26 weeks follow-up, determined objectively from coded GP electronic health records. Secondary outcomes will include patient reported outcome measures, and health and care service use. The main intention-to-treat analysis will use linear mixed effects regression to compare number of PIP indicators triggered at 26 weeks post-review between groups, adjusted for baseline (pre-randomisation) values. A nested process evaluation will explore implementation of the intervention in primary care. Ethics and dissemination The protocol and associated study materials have been approved by the Wales REC 6, NHS Research Ethics Committee (REC reference 19/WA/0090), host institution and Health Research Authority. Research outputs will be published in peer-reviewed journals and relevant conferences, and additionally disseminated to patients and the public, clinicians, commissioners and policy makers. ISRCTN Registration 90146150 (28/03/2019).
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Affiliation(s)
- Rupert A. Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Peter S. Blair
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Barbara Caddick
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, Medical Center of the Ludwig-Maximilians-University, Munich, Germany
| | - Lorna J. Duncan
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, University of Edinburgh, Edinburgh, UK
| | - Cindy Mann
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Jeff Round
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Chris Salisbury
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Katrina M. Turner
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Deborah McCahon
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Piñeiro-Pérez R, Ochoa-Sangrador C, López-Martín D, Martínez-Campos L, Calvo-Rey C, Nievas-Soriano BJ. Adherence of Spanish pediatricians to "do not do" guidelines to avoid low-value care in pediatrics. Eur J Pediatr 2022; 181:3965-3975. [PMID: 36102996 DOI: 10.1007/s00431-022-04613-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022]
Abstract
UNLABELLED The main objective of this study was to analyze the degree of knowledge and compliance of Spanish pediatricians with the "do not do" recommendations of the Spanish Association of Pediatrics. A nationwide cross-sectional, descriptive study was carried out using a 25-item questionnaire among Spanish pediatricians. Univariate, bivariate, and multivariate analyses were performed. A total of 1137 pediatricians participated in the study. Most of them were women (75.1%), older than 55 (28.3%), worked in specialized care (56.9%), with public financing (91.2%), and had been working for more than 20 years (44.9%). The median of inappropriate answers per question was 9.1%. The bivariate and multivariate analyses showed that the factors that influenced higher adequacy to the "do not do" recommendations were younger than 45 years, working in specialized care, and working in the public health system. CONCLUSION This research is the first nationwide study in Spain to analyze the adequacy of "do not do" pediatric clinical recommendations. The study showed a high level of compliance by Spanish pediatricians with these recommendations. However, there is a lack of knowledge in less frequent infectious pathologies such as HIV or fungal infections, in not prolonging antibiotic treatment unnecessarily and directing it appropriately according to the antibiogram results. These aspects may be improved by designing measures to enhance pediatricians' knowledge in these specific aspects. Some demographical factors are related to higher adequacy. Performing this research in other countries may allow assessing the current clinical practice of pediatricians. WHAT IS KNOWN • Low-value care is defined as care that delivers little or no benefit, may cause patients harm, or outcomes marginal benefits at a disproportionately increased cost. • Few nationwide studies have assessed adherence to "do not do" guidelines, especially in pediatric settings. WHAT IS NEW • Albeit there is a high level of compliance by Spanish pediatricians with the «do not do» recommendations, there is a lack of knowledge in different aspects that may be improved. • Some demographical factors are related to higher adequacy. Performing this research in other countries may allow assessing the current clinical practice of pediatricians.
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Affiliation(s)
- Roi Piñeiro-Pérez
- Pediatrics Service, Villalba General University Hospital, Collado-Villalba, Madrid, Spain
| | | | | | | | | | - Bruno José Nievas-Soriano
- Nursing, Physiotherapy, and Medicine Department, University of Almería, Ctra de Sacramento, s/n, 1410 La Cañada, Almería, Spain.
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Delemere E, Liston P. Exploring the Use of Behavioural Techniques in Serious Games for Energy Efficiency: a Systematic Review and Content Analysis. BEHAVIOR AND SOCIAL ISSUES 2022. [DOI: 10.1007/s42822-022-00103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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166
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Odawara M, Saito J, Yaguchi-Saito A, Fujimori M, Uchitomi Y, Shimazu T. Using implementation mapping to develop strategies for preventing non-communicable diseases in Japanese small- and medium-sized enterprises. Front Public Health 2022; 10:873769. [PMID: 36276371 PMCID: PMC9582744 DOI: 10.3389/fpubh.2022.873769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Workplace programs to prevent non-communicable diseases (NCDs) in the workplace can help prevent the incidence of chronic diseases among employees, provide health benefits, and reduce the risk of financial loss. Nevertheless, these programs are not fully implemented, particularly in small- and medium-sized enterprises (SMEs). The purpose of this study was to develop implementation strategies for health promotion activities to prevent NCDs in Japanese SMEs using Implementation Mapping (IM) to present the process in a systematic, transparent, and replicable manner. Methods Qualitative methods using interviews and focus group discussions with 15 SMEs and 20 public health nurses were conducted in a previous study. This study applied the Consolidated Framework for Implementation Research and IM to analyze this dataset to develop implementation strategies suitable for SMEs in Japan. Results In task 2 of the IM, we identified performance objectives, determinants, and change objectives for each implementation stage: adoption, implementation, and maintenance; to identify the required actors and actions necessary to enhance implementation effectiveness. Twenty-two performance objectives were identified in each implementation stage. In task 3 of the IM, the planning group matched behavioral change methods (e.g., modeling and setting of graded tasks, framing, self-re-evaluation, and environmental re-evaluation) with determinants to address the performance objectives. We used a consolidated framework for implementation research to select the optimal behavioral change technique for performance objectives and determinants and designed a practical application. The planning team agreed on the inclusion of sixteen strategies from the final strategies list compiled and presented to it for consensus, for the overall implementation plan design. Discussion This paper provides the implementation strategies for NCDs prevention for SMEs in Japan following an IM protocol. Although the identified implementation strategies might not be generalizable to all SMEs planning implementation of health promotion activities, because they were tailored to contextual factors identified in a formative research. However, identified performance objectives and implementation strategies can help direct the next steps in launching preventive programs against NCDs in SMEs.
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Affiliation(s)
- Miyuki Odawara
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Junko Saito
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Akiko Yaguchi-Saito
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Maiko Fujimori
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Tokyo, Japan
- Division of Supportive Care, Survivorship and Translational Research, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Yosuke Uchitomi
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Tokyo, Japan
- Division of Supportive Care, Survivorship and Translational Research, National Cancer Center Institute for Cancer Control, Tokyo, Japan
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, Tokyo, Japan
| | - Taichi Shimazu
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Tokyo, Japan
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Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres. S Afr Med J 2022; 112:812-818. [PMID: 36472332 DOI: 10.7196/samj.2022.v112i10.16397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The increasing prevalence of antibiotic resistance is a major threat to public health. Primary care, where 80% of antibiotics are consumed, is a pivotal setting to direct antimicrobial stewardship (AMS) efforts. However, the ideal model to improve antibiotic prescribing in primary care in low-resource settings is not known. OBJECTIVE To implement a multidisciplinary audit and feedback AMS intervention with the aim to improve appropriate antibiotic prescribing at primary care level. METHODS The intervention was implemented and monitored in 10 primary care centres of the Cape Town metropole between July 2017 and June 2019. The primary and secondary outcome measures were monthly adherence to a bundle of antibiotic quality process measures and monthly antibiotic consumption, respectively. Multidisciplinary audit and feedback meetings were initiated and integrated into facility clinical meetings. Two Excel tools were utilised to automatically calculate facility audit scores and consumption. Once a month, 10 antibiotic prescriptions were randomly selected for a peer review audit by the team. The prescriptions were audited for adherence to a bundle of seven antibiotic process measures using the standard treatment guidelines (STG) and Essential Medicines List (EML) as standard. Concurrently, primary care pharmacists monitored monthly antibiotic consumption by calculating defined daily doses (DDDs) per 100 prescriptions dispensed. Adherence and consumption feedback were regularly provided to the facilities. Learning collaboratives involving representative multidisciplinary teams were held twice-yearly. Pre-, baseline and post-intervention periods were defined as 6 months before, first 6 months and last 6 months of the study, respectively. RESULTS The mean overall adherence increased from 19% (baseline) to 47% (post intervention) (p<0.001). Of the 2 077 prescriptions analysed, 33.7% had an antibiotic prescribed inappropriately. No diagnosis had been captured in patient notes, and the antibiotic chosen was not according to the STG and EML in 30.1% and 31.7% of cases, respectively. Seasonal variation was observed in prescribing adherence, with significantly lower adherence in winter and spring months (adjusted odds ratio 0.60). A reduction of 12.9 DDDs between the pre- and post-intervention periods (p=0.0084) was documented, which represented a 19.3% decrease in antibiotic consumption. CONCLUSION The study demonstrated that peer reviewed audit and feedback is an effective AMS intervention to improve antibiotic prescribing in primary care in a low-resource setting. The intervention, utilising existing resources and involving multidisciplinary engagement, may be incorporated into existing quality improvement processes at facility level, to ensure sustainable change.
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Safety and Quality in Maternal and Neonatal Care: Any Progress since Ignaz Semmelweis? Healthcare (Basel) 2022; 10:healthcare10101876. [PMID: 36292323 PMCID: PMC9602043 DOI: 10.3390/healthcare10101876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/09/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
James Lind (1716–1794) is considered the pioneer of medical technology assessments [...]
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169
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The Influence of Health Behavior Theory on Implementation Practice and Science: Brief Review and Commentary. PHARMACY 2022; 10:pharmacy10050115. [PMID: 36136848 PMCID: PMC9498588 DOI: 10.3390/pharmacy10050115] [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] [Received: 08/11/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 11/22/2022] Open
Abstract
As research defines new treatments and policies to improve the health of patients, an increasing challenge has been to translate these insights into routine clinical practice to benefit patients and society. An important exploration is how theories of human behavior change fit into the science of implementation and quality improvement. In this paper, we begin with a brief review of the intellectual roots of implementation science and quality improvement, followed by a discussion of how theories and principles of behavior change can inform both goals and challenges in using behavior change theories. The insights offered through health behavior change theory have led to changes in how we plan for implementation and select, develop, design and tailor implementation interventions and strategies. While the degree to which organizational and external contexts influence the behavior of providers in these organizations varies widely, some degree of context external to the individual is important and needs adequate consideration. In short, health behavior change theory is essential but not sufficient to integrate in most implementation efforts, where priority must be given to both individual factors and contexts in which individuals operate.
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170
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Barriers and Facilitators to Data Use for Decision Making: The Experience of the African Health Initiative Partnerships in Ethiopia, Ghana, and Mozambique. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100666. [PMID: 36109056 PMCID: PMC9476487 DOI: 10.9745/ghsp-d-21-00666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/07/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Three African Health Initiative (AHI) partnership projects in Ethiopia, Ghana, and Mozambique implemented strategies to improve the quality and evaluation of routinely collected data at the primary health care level and stimulate its use in evidence-based decision making. We compare how these programs designed and carried out data for decision-making (DDM) strategies, elaborate on barriers and facilitators to implementation success, and offer recommendations for future DDM programming. METHODS Researchers from each project collaboratively wrote a cross-country protocol based on these objectives. By adapting the Consolidated Framework for Implementation Research (CFIR) through a qualitative theme reduction process, they harmonized lines of inquiry on the design of the respective DDM strategies and the barriers and facilitators of effective implementation. We conducted in-depth interviews and focus group discussions with stakeholders from the primary health care systems in each country, and we carried out multistage, thematic analyses using a deductive lens. RESULTS Effective implementation of DDM depended on whether implementers felt that DDM was adaptable to context, feasible to trial, and easy to introduce and maintain. The prevailing policy and political environment in the wider health system, learning climate and absorptive capacity for evidence-based change in DDM settings, engagement of external change agents and internal change leaders, and promotion of opportunities and means for team-based reflection and evaluations of what works influenced the success or failure of DDM strategies. CONCLUSION Opportunities for team-based capacity building and individual mentorship led to effective DDM programming. External policies and associated incentives bolstered this but occasionally led to unintended consequences. Leadership engagement and availability of resources to act on recommendations; respond to capacity-building needs; and facilitate collaborations between peers, within hierarchies, and across the local health system proved crucial to DDM, as was encouraging adaptation and opportunities for iterative on-the-job learning.
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Inguane C, Soi C, Gimbel S, Manaca N, Ramiro I, Floriano F, Castro GD, Augusto O, Tembe S, Pfeiffer J, Fernandes Q, Sherr K. Applying the Consolidated Framework for Implementation Research to Identify Implementation Determinants for the Integrated District Evidence-to-Action Program, Mozambique. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100714. [PMID: 36109061 PMCID: PMC9476477 DOI: 10.9745/ghsp-d-21-00714] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 06/10/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The Integrated District Evidence-to-Action program is an audit and feedback intervention introduced in 2017 in Manica and Sofala provinces, Mozambique, to reduce mortality in children younger than 5 years. We describe barriers and facilitators to early-stage effectiveness of that intervention. METHOD We embedded the Consolidated Framework for Implementation Research (CFIR) into an extended case study design to inform sampling, data collection, analysis, and interpretation. We collected data in 4 districts in Manica and Sofala Provinces in November 2018. Data collection included document review, 22 in-depth individual interviews, and 2 focus group discussions (FGDs) with 19 provincial, district, and facility managers and nurses. Most participants (70.2%) were nurses and facility managers and the majority were women (87.8%). We audio-recorded all but 2 interviews and FGDs and conducted a consensus-based iterative analysis. RESULTS Facilitators of effective intervention implementation included: implementation of the core intervention components of audit and feedback meetings, supportive supervision and mentorship, and small grants as originally planned; positive pressure from district managers and study nurses on health facility staff to strive for excellence; and easy access to knowledge and information about the intervention. Implementation barriers were the intervention's lack of compatibility in not addressing the scarcity of human and financial resources and inadequate infrastructures for maternal and child health services at district and facility levels and; the intervention's lack of adaptability in having little flexibility in the design and decision making about the use of intervention funds and data collection tools. DISCUSSION Our comprehensive and systematic use of the CFIR within an extended case study design generated granular evidence on CFIR's contribution to implementation science efforts to describe determinants of early-stage intervention implementation. It also provided baseline findings to assess subsequent implementation phases, considering similarities and differences in barriers and facilitators across study districts and facilities. Sharing preliminary findings with stakeholders promoted timely decision making about intervention implementation.
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Affiliation(s)
- Celso Inguane
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Sarah Gimbel
- Department of Family and Child Nursing, University of Washington, Seattle, WA, USA
| | - Nélia Manaca
- Health Alliance International, Beira and Chimoio, Mozambique
| | - Isaías Ramiro
- Comité para a Saúde de Moçambique, Maputo City, Mozambique
| | | | | | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Community Health, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo City, Mozambique
| | - Stélio Tembe
- Department of Global Health, University of Washington, Seattle, WA, USA
- National Directorate of Public Health, Ministry of Health, Maputo City, Mozambique
| | - James Pfeiffer
- Department of Global Health, University of Washington, Seattle, WA, USA
- Health Alliance International, Seattle, WA, USA
| | - Quinhas Fernandes
- Department of Global Health, University of Washington, Seattle, WA, USA
- National Directorate of Public Health, Ministry of Health, Maputo City, Mozambique
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
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Korenstein D, Gillespie EF. Audit and Feedback-Optimizing a Strategy to Reduce Low-Value Care. JAMA 2022; 328:833-835. [PMID: 36066538 DOI: 10.1001/jama.2022.14173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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James MT, Har BJ, Tyrrell BD, Faris PD, Tan Z, Spertus JA, Wilton SB, Ghali WA, Knudtson ML, Sajobi TT, Pannu NI, Klarenbach SW, Graham MM. Effect of Clinical Decision Support With Audit and Feedback on Prevention of Acute Kidney Injury in Patients Undergoing Coronary Angiography: A Randomized Clinical Trial. JAMA 2022; 328:839-849. [PMID: 36066520 PMCID: PMC9449791 DOI: 10.1001/jama.2022.13382] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes. OBJECTIVE To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI. DESIGN, SETTING, AND PARTICIPANTS A stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020. INTERVENTIONS During the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention. MAIN OUTCOMES AND MEASURES The primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models. RESULTS Of the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 [SD, 10.7] years; 1384 were women [32.0%]) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 [SD, 10.8] years; 1151 were women [33.0%]). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, -2.3% [95% CI, -0.6% to -4.1%]; odds ratio [OR], 0.72 [95% CI, 0.56 to 0.93]; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, -12.0% [95% CI, -14.4% to -9.4%]; OR, 0.77 [95% CI, 0.65 to 0.90]; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, -15.8% [95% CI, -19.7% to -12.0%]; OR, 0.68 [95% CI, 0.53 to 0.87]; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events. CONCLUSIONS AND RELEVANCE Among cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03453996.
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Affiliation(s)
- Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Bryan J. Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benjamin D. Tyrrell
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- CK Hui Heart Centre, University of Alberta, Edmonton, Canada
| | | | - Zhi Tan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John A. Spertus
- Departments of Biomedical and Health Informatics, University of Missouri, Kansas City
- Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Stephen B. Wilton
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William A. Ghali
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Merril L. Knudtson
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tolulope T. Sajobi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Neesh I. Pannu
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Scott W. Klarenbach
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Michelle M. Graham
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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174
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O’Connor DA, Glasziou P, Maher CG, McCaffery KJ, Schram D, Maguire B, Ma R, Billot L, Gorelik A, Traeger AC, Albarqouni L, Checketts J, Vyas P, Clark B, Buchbinder R. Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial. JAMA 2022; 328:850-860. [PMID: 36066518 PMCID: PMC9449798 DOI: 10.1001/jama.2022.14587] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. OBJECTIVE To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). DESIGN, SETTING, AND PARTICIPANTS This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. INTERVENTIONS Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. MAIN OUTCOMES AND MEASURES The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. RESULTS A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). CONCLUSIONS AND RELEVANCE Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. TRIAL REGISTRATION ANZCTR Identifier: ACTRN12619001503112.
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Affiliation(s)
- Denise A. O’Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Christopher G. Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Kirsten J. McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Dina Schram
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brigit Maguire
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Robert Ma
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Adrian C. Traeger
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Juliet Checketts
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Parima Vyas
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brett Clark
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
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175
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Haut ER, Owodunni OP, Wang J, Shaffer DL, Hobson DB, Yenokyan G, Kraus PS, Farrow NE, Canner JK, Florecki KL, Webster KLW, Holzmueller CG, Aboagye JK, Popoola VO, Kia MV, Pronovost PJ, Streiff MB, Lau BD. Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial. J Am Heart Assoc 2022; 11:e027119. [PMID: 36047732 DOI: 10.1161/jaha.122.027119] [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] [Indexed: 11/16/2022]
Abstract
Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.
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Affiliation(s)
- Elliott R Haut
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD.,Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Surgery Center for Outcomes Research Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | | - Jiangxia Wang
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Dauryne L Shaffer
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Department of Nursing The Johns Hopkins Hospital Baltimore MD
| | - Deborah B Hobson
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Nursing The Johns Hopkins Hospital Baltimore MD
| | - Gayane Yenokyan
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Peggy S Kraus
- Department of Pharmacy The Johns Hopkins Hospital Baltimore MD
| | - Norma E Farrow
- Department of Surgery Duke University Medical Center Durham NC
| | - Joseph K Canner
- The Johns Hopkins Surgery Center for Outcomes Research Johns Hopkins University School of Medicine Baltimore MD
| | | | - Kristen L W Webster
- Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Christine G Holzmueller
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD
| | - Jonathan K Aboagye
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Victor O Popoola
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD.,Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Mujan Varasteh Kia
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Peter J Pronovost
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Michael B Streiff
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD
| | - Brandyn D Lau
- Division of Health Sciences Informatics, Russell H. Morgan Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
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176
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Gjata I, Olivieri L, Baghirzada L, Endersby RVW, Solbak NM, Weaver CGW, Law S, Cooke LJ, Burak KW, Dowling SK. The effectiveness of a multifaceted, group-facilitated audit and feedback intervention to increase tranexamic acid use during total joint arthroplasty. Can J Anaesth 2022; 69:1129-1138. [PMID: 35877041 DOI: 10.1007/s12630-022-02236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/21/2021] [Accepted: 01/22/2022] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Intraoperative tranexamic acid (TXA) is used to reduce blood loss and the need for transfusions following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Despite evidence in literature and local practice protocols supporting TXA as a part of standard of care for joint arthroplasty, TXA administration is underutilized. We aimed to use group-facilitated audit and feedback as the foundation of a knowledge translation strategy to increase TXA use for THA and TKA procedures. METHODS Anesthesiologists consented to receive two data reports summarizing their individual rates of TXA use and postoperative blood transfusions compared with site peers. Variables collected included patient demographics, TXA usage, and the frequency and volume of red blood cell transfusions administered in the 72-hr postoperative period. The facilitated feedback session discussed report findings and focused on factors contributing to local practice patterns and opportunities for change. RESULTS Tranexamic acid use increased for THA procedures at the intervention site from 66.6 to 74.4% (absolute change, 7.9%; 95% confidence interval [CI], 2.4 to 13.3). Likewise, TXA use for TKA procedures increased from 62.4 to 82.3% (absolute change, 19.9%; 95% CI 15.0 to 25.0). CONCLUSIONS Physicians and their teams were able to review their practice data on TXA utilization, reflect on differences compared with evidence-based guidelines, discuss findings with peers, and identify opportunities for improvement. The intervention increased the use of TXA for both TKA and THA and shifted the dosage to better align with evidence-based practice guidelines.
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Affiliation(s)
- Inelda Gjata
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lori Olivieri
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Leyla Baghirzada
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ryan V W Endersby
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nathan M Solbak
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Colin G W Weaver
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Health Services Statistical and Analytic Methods, Analytics, Alberta Health Services, Calgary, AB, Canada
| | - Sampson Law
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lara J Cooke
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kelly W Burak
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shawn K Dowling
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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177
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Wu C, O'Keeffe C, Sanford J, Hagel J, Childs S, Evers G, Melbourne J, West C, Koch M, Cornia PB. Simple signature/countersignature shared-accountability quality improvement initiative to improve reliability of blood sample collection: an essential clinical task. BMJ Open Qual 2022; 11:bmjoq-2021-001765. [PMID: 36130832 PMCID: PMC9494581 DOI: 10.1136/bmjoq-2021-001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 08/19/2022] [Indexed: 11/04/2022] Open
Abstract
Background Timely lab results are important to clinical decision-making and hospital flow. However, at our institution, unreliable blood sample collection for patients with central venous access jeopardised this outcome and created staff dissatisfaction. Methods A multidisciplinary team of nurses including a specialist clinical nurse leader (CNL), the hospital intravenous team and quality improvement (QI) consultants aimed to achieve >80% blood sample collection reliability among patients with central venous access by employing a simple signature/countersignature form coupled with audit-feedback and behavioural economics strategies. The form was piloted on one 25-bed unit. Data were collected for 60 weeks and interpreted per standard run chart rules. Results Blood sample collection reliability exceeded the 80% goal by week 22. The practice was sustained on the pilot unit and spread successfully to other wards despite significant operational threats including the COVID-19 pandemic. Conclusions At our institution, a simple signature/countersignature form supplemented by audit-feedback and behavioural economics strategies led to sustained practice change among staff. The pairing of CNL to QI consultant enhanced change potency and durability.
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Affiliation(s)
- Chenwei Wu
- Hospital and Specialty Medicine, VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Chatty O'Keeffe
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Jesse Sanford
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Jean Hagel
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Shelia Childs
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Gary Evers
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Julie Melbourne
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Collyn West
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Michael Koch
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
| | - Paul B Cornia
- Hospital and Specialty Medicine, VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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178
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Dekker E, Nass KJ, Iacucci M, Murino A, Sabino J, Bugajski M, Carretero C, Cortas G, Despott EJ, East JE, Kaminski MF, Karstensen JG, Keuchel M, Löwenberg M, Monged A, Nardone OM, Neumann H, Omar MM, Pellisé M, Peyrin-Biroulet L, Rutter MD, Bisschops R. Performance measures for colonoscopy in inflammatory bowel disease patients: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2022; 54:904-915. [PMID: 35913069 DOI: 10.1055/a-1874-0946] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The European Society of Gastrointestinal Endoscopy (ESGE) presents a short list of performance measures for colonoscopy in inflammatory bowel disease (IBD) patients. Current performance measures for colonoscopy mainly focus on detecting (pre)malignant lesions. However, these performance measures are not relevant for all colonoscopy indications in IBD patients. Therefore, our aim was to provide endoscopy services across Europe and other interested countries with a tool for quality monitoring and improvement in IBD colonoscopy. Eight key performance measures and one minor performance measure were recommended for measurement and evaluation in daily endoscopy practice.
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Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Karlijn J Nass
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, London, UK
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospital Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Marek Bugajski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Cristina Carretero
- Department of Gastroenterology, University of Navarre Clinic, Healthcare Research Institute of Navarre, Pamplona, Spain
| | - George Cortas
- University of Balamand Faculty of Medicine, St. George Hospital University Medical Center, Beirut, Lebanon
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, London, UK
| | - James E East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Division of Gastroenterology and Hepatology, Mayo Clinic Healthcare, London, UK
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ashraf Monged
- Endoscopy Unit, Royal College of Surgeons of Ireland Hospitals Group, Dublin, Ireland
| | - Olga M Nardone
- Institute of Translational Medicine and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Gastroenterology, Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany
| | - Mahmoud M Omar
- Department of Internal Medicine, Digestive Diseases and Endoscopy, New Mowasat Hospital, Salmiya, Kuwait
| | - Maria Pellisé
- Gastroenterology Department, Endoscopy Unit, ICMDiM, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Catalonia, Spain
| | | | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, TARGID, KU Leuven, Leuven, Belgium
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179
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Tsang TW, Kingsland M, Doherty E, Wiggers J, Attia J, Wolfenden L, Dunlop A, Tully B, Symonds I, Rissel C, Lecathelinais C, Elliott EJ. Effectiveness of a practice change intervention in reducing alcohol consumption in pregnant women attending public maternity services. Subst Abuse Treat Prev Policy 2022; 17:63. [PMID: 36045392 PMCID: PMC9429389 DOI: 10.1186/s13011-022-00490-2] [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] [Accepted: 08/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to examine the effect of a practice change intervention to support the implementation of guideline-recommended care for addressing alcohol use in pregnancy on self-reported alcohol use during pregnancy. Methods A randomized, stepped-wedge controlled trial in three clusters (sectors) within the Hunter New England Local Health District (NSW, Australia). We evaluated a practice change intervention that supported the introduction of a new model of care for reducing alcohol use in pregnancy, consistent with local and international guidelines, and implemented in random order across the sectors. Each week throughout the study period, pregnant women who attended any public antenatal services within the previous week, for a 27–28 or 35–36 week gestation visit, were randomly sampled and invited to participate in the survey. The intended intervention for all women was Brief advice (to abstain from alcohol and information about potential risks). Women identified as medium-risk alcohol consumers using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) were to be offered referral to a phone coaching service, and women identified as high-risk were to be offered referral to a Drug and Alcohol Service. Rates of self-reported alcohol use (AUDIT-C risk level and special occasion drinking) were summarized and compared in groups of women pre-intervention and post-intervention using multivariable logistic regression. Results Surveys were completed by 1309 women at pre-intervention and 2540 at post-intervention. The majority of women did not drink during pregnancy (pre-intervention: 89.68%; post-intervention: 90.74%). There was no change in the proportion of women classified as No risk from drinking (AUDIT-C score = 0) or Some risk from drinking (AUDIT-C score ≥ 1) pre- or post-intervention (p = 0.08). However, a significant reduction in special occasion drinking was observed (pre-intervention: 11.59%; post-intervention: 8.43%; p < 0.001). Conclusions Special occasion drinking was reduced following implementation of guideline-recommended care. Failure to change other patterns of alcohol use in pregnancy may reflect barriers to implementing the model of care in antenatal care settings and the need to address other social determinants of alcohol use. Trial registration Australian and New Zealand Clinical Trials Registry (registration number: ACTRN12617000882325; date: 16 June 2017).
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Henderson CE, Plawecki A, Lucas E, Lotter JK, Scofield M, Carbone A, Jang JH, Hornby TG. Increasing the Amount and Intensity of Stepping Training During Inpatient Stroke Rehabilitation Improves Locomotor and Non-Locomotor Outcomes. Neurorehabil Neural Repair 2022; 36:621-632. [PMID: 36004813 DOI: 10.1177/15459683221119759] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The efficacy of traditional rehabilitation interventions to improve locomotion post-stroke, including providing multiple exercises targeting impairments and activity limitations, is uncertain. Emerging evidence rather suggests attempts to prioritize stepping practice at higher cardiovascular intensities may facilitate greater locomotor outcomes. OBJECTIVE The present study was designed to evaluate the comparative effectiveness of high-intensity training (HIT) to usual care during inpatient rehabilitation post-stroke. METHODS Changes in stepping activity and functional outcomes were compared over 9 months during usual-care (n = 131 patients < 2 months post-stroke), during an 18-month transition phase with attempts to implement HIT (n = 317), and over 12 months following HIT implementation (n = 208). The transition phase began with didactic and hands-on education, and continued with meetings, mentoring, and audit and feedback. Fidelity metrics included percentage of sessions prioritizing gait interventions and documenting intensity. Demographics, training measures, and outcomes were compared across phases using linear or logistic regression analysis, Kruskal-Wallis tests, or χ2 analysis. RESULTS Across all phases, admission scores were similar except for balance (usual-care>HIT; P < .02). Efforts to prioritize stepping and achieve targeted intensities during HIT vs transition or usual-care phases led to increased steps/day (P < .01). During HIT, gains in 10-m walk [HIT median = 0.13 m/s (interquartile range: 0-0.35) vs usual-care = 0.07 m/s (0-0.24), P = .01] and 6-min walk [50 (9.3-116) vs 2.1 (0-56) m, P < .01] were observed, with additional improvements in transfers and stair-climbing. CONCLUSIONS Greater efforts to prioritize walking and reach higher intensities during HIT led to increased steps/day, resulting in greater gains in locomotor and non-locomotor outcomes.
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Affiliation(s)
- Christopher E Henderson
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Abbey Plawecki
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Emily Lucas
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | | | - Molly Scofield
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Angela Carbone
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Jeong H Jang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T George Hornby
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
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181
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Rapin J, Pellet J, Mabire C, Gendron S, Dubois CA. How does nursing-sensitive indicator feedback with nursing or interprofessional teams work and shape nursing performance improvement systems? A rapid realist review. Syst Rev 2022; 11:177. [PMID: 36002846 PMCID: PMC9404638 DOI: 10.1186/s13643-022-02026-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care quality varies between organizations and even units within an organization. Inadequate care can have harmful financial and social consequences, e.g. nosocomial infection, lengthened hospital stays or death. Experts recommend the implementation of nursing performance improvement systems to assess team performance and monitor patient outcomes as well as service efficiency. In practice, these systems provide nursing or interprofessional teams with nursing-sensitive indicator feedback. Feedback is essential since it commits teams to improve their practice, although it appears somewhat haphazard and, at times, overlooked. Research findings suggest that contextual dynamics, initial system performance and feedback modes interact in unknown ways. This rapid review aims to produce a theorization to explain what works in which contexts, and how feedback to nursing or interprofessional teams shape nursing performance improvement systems. METHODS Based on theory-driven realist methodology, with reference to an innovative combination of Actor-Network Theory and Critical Realist philosophy principles, this realist rapid review entailed an iterative procedure: 8766 documents in French and English, published between 2010 and 2018, were identified via 5 databases, and 23 were selected and analysed. Two expert panels (scientific and clinical) were consulted to improve the synthesis and systemic modelling of an original feedback theorization. RESULTS We identified three hypotheses, subdivided into twelve generative configurations to explain how feedback mobilizes nursing or interprofessional teams. Empirically founded and actionable, these propositions are supported by expert panels. Each configuration specifies contextualized mechanisms that explain feedback and team outcomes. Socially mediated mechanisms are particularly generative of action and agency. CONCLUSIONS This rapid realist review provides an informative theoretical proposition to embrace the complexity of nursing-sensitive indicator feedback with nursing or interdisciplinary teams. Building on general explanations previously observed, this review provides insight into a deep explanation of feedback mechanisms. SYSTEMATIC REVIEW REGISTRATION Prospero CRD42018110128 .
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Affiliation(s)
- Joachim Rapin
- Faculty of Nursing, Université de Montréal, 2375 Chemin de la Côte-Sainte-Catherine, Montréal, Québec, H3T 1A8, Canada. .,Lausanne University Hospital, rue du Bugnon 21, CH - 1011, Lausanne, Switzerland.
| | - Joanie Pellet
- Lausanne University Hospital, rue du Bugnon 21, CH - 1011, Lausanne, Switzerland.,Institute of Higher Education and Research in Healthcare - IUFRS, University of Lausanne, Biopôle 2 - Route de la Corniche 10, CH - 1010, Lausanne, Switzerland
| | - Cédric Mabire
- Lausanne University Hospital, rue du Bugnon 21, CH - 1011, Lausanne, Switzerland.,Institute of Higher Education and Research in Healthcare - IUFRS, University of Lausanne, Biopôle 2 - Route de la Corniche 10, CH - 1010, Lausanne, Switzerland
| | - Sylvie Gendron
- Faculty of Nursing, Université de Montréal, 2375 Chemin de la Côte-Sainte-Catherine, Montréal, Québec, H3T 1A8, Canada
| | - Carl-Ardy Dubois
- École de Santé Publique de L'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
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Dorr MC, van Hof KS, Jelsma JGM, Dronkers EAC, de Jong RJB, Offerman MPJ, de Bruijne MC. Quality improvements of healthcare trajectories by learning from aggregated patient-reported outcomes: a mixed-methods systematic literature review. Health Res Policy Syst 2022; 20:90. [PMID: 35978425 PMCID: PMC9387033 DOI: 10.1186/s12961-022-00893-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background In healthcare, analysing patient-reported outcome measures (PROMs) on an aggregated level can improve and regulate healthcare for specific patient populations (meso level). This mixed-methods systematic review aimed to summarize and describe the effectiveness of quality improvement methods based on aggregated PROMs. Additionally, it aimed to describe barriers, facilitators and lessons learned when using these quality improvement methods. Methods A mixed-methods systematic review was conducted. Embase, MEDLINE, CINAHL and the Cochrane Library were searched for studies that described, implemented or evaluated a quality improvement method based on aggregated PROMs in the curative hospital setting. Quality assessment was conducted via the Mixed Methods Appraisal Tool. Quantitative data were synthesized into a narrative summary of the characteristics and findings. For the qualitative analysis, a thematic synthesis was conducted. Results From 2360 unique search records, 13 quantitative and three qualitative studies were included. Four quality improvement methods were identified: benchmarking, plan-do-study-act cycle, dashboards and internal statistical analysis. Five studies reported on the effectiveness of the use of aggregated PROMs, of which four identified no effect and one a positive effect. The qualitative analysis identified the following themes for facilitators and barriers: (1) conceptual (i.e. stakeholders, subjectivity of PROMs, aligning PROMs with clinical data, PROMs versus patient-reported experience measures [PREMs]); (2a) methodological—data collection (i.e. choice, timing, response rate and focus); (2b) methodological—data processing (i.e. representativeness, responsibility, case-mix control, interpretation); (3) practical (i.e. resources). Conclusion The results showed little to no effect of quality improvement methods based on aggregated PROMs, but more empirical research is needed to investigate different quality improvement methods. A shared stakeholder vision, selection of PROMs, timing of measurement and feedback, information on interpretation of data, reduction of missing data, and resources for data collection and feedback infrastructure are important to consider when implementing and evaluating quality improvement methods in future research. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00893-4. What is already known on this topic The aggregated patient-reported outcome measures (PROMs) can be used for analytical and organizational aspects of improving and regulating healthcare, but there is little empirical evidence regarding the effectiveness of aggregated PROMS. What this study adds This study adds a detailed overview of the types of quality improvement methods and recommendations for implementation in practice. How this study might affect research, practice or policy Researchers and policy-makers should consider the barriers, facilitators and lessons learned for future implementation and evaluation of quality improvement methods, as presented in this manuscript, to further advance this field.
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Affiliation(s)
- Maarten C Dorr
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - K S van Hof
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - J G M Jelsma
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - E A C Dronkers
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - R J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - M P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - M C de Bruijne
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
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Lawson DO, Wang MK, Kim K, Eikelboom R, Rodrigues M, Trapsa D, Thabane L, Moher D. Lessons from the COVID-19 pandemic and recent developments on the communication of clinical trials, publishing practices, and research integrity: in conversation with Dr. David Moher. Trials 2022; 23:671. [PMID: 35978325 PMCID: PMC9383655 DOI: 10.1186/s13063-022-06624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The torrent of research during the coronavirus (COVID-19) pandemic has exposed the persistent challenges with reporting trials, open science practices, and scholarship in academia. These real-world examples provide unique learning opportunities for research methodologists and clinical epidemiologists-in-training. Dr. David Moher, a recognized expert on the science of research reporting and one of the founders of the Consolidated Standards of Reporting Trials (CONSORT) statement, was a guest speaker for the 2021 Hooker Distinguished Visiting Professor Lecture series at McMaster University and shared his insights about these issues. MAIN TEXT This paper covers a discussion on the influence of reporting guidelines on trials and issues with the use of CONSORT as a measure of quality. Dr. Moher also addresses how the overwhelming body of COVID-19 research reflects the "publish or perish" paradigm in academia and why improvement in the reporting of trials requires policy initiatives from research institutions and funding agencies. We also discuss the rise of publication bias and other questionable reporting practices. To combat this, Dr. Moher believes open science and training initiatives led by institutions can foster research integrity, including the trustworthiness of researchers, institutions, and journals, as well as counter threats posed by predatory journals. He highlights how metrics like journal impact factor and quantity of publications also harm research integrity. Dr. Moher also discussed the importance of meta-science, the study of how research is carried out, which can help to evaluate audit and feedback systems and their effect on open science practices. CONCLUSION Dr. Moher advocates for policy to further improve the reporting of trials and health research. The COVID-19 pandemic has exposed how a lack of open science practices and flawed systems incentivizing researchers to publish can harm research integrity. There is a need for a culture shift in assessing careers and "productivity" in academia, and this requires collaborative top-down and bottom-up approaches.
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Affiliation(s)
- Daeria O Lawson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael K Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Kevin Kim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rachel Eikelboom
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Myanca Rodrigues
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniela Trapsa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada.
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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McIntyre D, Bonner A, McGuire A. Validation of the McIntyre Audit Tool to measure haemodialysis nurse sensitive indicators. J Ren Care 2022. [PMID: 35975294 DOI: 10.1111/jorc.12441] [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: 05/07/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nurse sensitive indicators measure the quality of nursing care. Although there are some haemodialysis nurse sensitive indicators, there are currently no validated audit tools available to measure the indicators. OBJECTIVES To test the validity of the McIntyre Audit Tool. DESIGN This study used a descriptive observation design conducted over two phases to assess face and content validity. PARTICIPANTS An expert panel of haemodialysis nurses (n = 13). METHODS Face validity (phase 1) involved 13 nurses in two focus groups who reviewed the audit tool with qualitative data generated analysed to identify common themes. Phase 2 used a modified version of the audit tool to test for content validity for each item and then scale level content validity was calculated by combining all item scores. MEASUREMENTS Ten nurses rated 26 indicators in the audit tool using a 4-point Likert scale to assess each item for clarity, relevance, appropriateness, and ambiguity. RESULTS All 26-haemodialysis nurse sensitive indicators achieved item content validity indices ranging from 0.825 to 1.00 with a scale content validity index average of 0.910. However, based on feedback from phase 2, 6 outcome indicators were removed from the audit tool to reduce staff burden and assist with ease of use. The final audit tool had an excellent average scale content validity index of 0.924. CONCLUSIONS The McIntyre Audit Tool to measure 20 haemodialysis nurse sensitive indicators has been validated. It now requires feasibility and reliability testing before auditing the quality of haemodialysis nursing care.
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Affiliation(s)
- David McIntyre
- School of Nursing, Griffith University, Brisbane, Australia.,Kidney Health Service, Townsville University Hospital, Townsville, Australia
| | - Ann Bonner
- School of Nursing, Griffith University, Brisbane, Australia.,Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Amanda McGuire
- School of Nursing, Griffith University, Brisbane, Australia
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185
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Schüttig W, Flemming R, Mosler CH, Leve V, Reddemann O, Schultz A, Brua E, Brittner M, Meyer F, Pollmanns J, Martin J, Czihal T, von Stillfried D, Wilm S, Sundmacher L. Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany. BMC Health Serv Res 2022; 22:1015. [PMID: 35945585 PMCID: PMC9364554 DOI: 10.1186/s12913-022-08327-1] [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] [Received: 12/17/2021] [Accepted: 07/13/2022] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients. METHODS Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients. RESULTS The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure. CONCLUSION Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.
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Affiliation(s)
- Wiebke Schüttig
- Chair of Health Economics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany. .,Department for Health Services Management, Ludwig-Maximilian-University Munich, Munich, Germany.
| | - Ronja Flemming
- Chair of Health Economics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany.,Department for Health Services Management, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Christiane Höhling Mosler
- AOK Health Insurance Rhineland / Hamburg, Kasernenstraße 61, 40213, Duesseldorf, Germany.,University Hospital Düsseldorf, Office of Quality Management and Patient Safety, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Verena Leve
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Olaf Reddemann
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Annemarie Schultz
- Regional Association of Statutory Health Insurance Physicians Hamburg, Humboldtstraße 56, 22083, Hamburg, Germany
| | - Emmanuelle Brua
- Regional Association of Statutory Health Insurance Physicians Hamburg, Humboldtstraße 56, 22083, Hamburg, Germany
| | - Matthias Brittner
- Regional Association of Statutory Health Insurance Physicians Westphalia Lip, Robert-Schimrigk-Straße 4-6, 44141, Dortmund, Germany
| | - Frank Meyer
- Regional Association of Statutory Health Insurance Physicians Westphalia Lip, Robert-Schimrigk-Straße 4-6, 44141, Dortmund, Germany
| | - Johannes Pollmanns
- Regional Association of Statutory Health Insurance Physicians North Rhine, Tersteegenstraße 9, 40474, Duesseldorf, Germany
| | - Johnannes Martin
- Regional Association of Statutory Health Insurance Physicians North Rhine, Tersteegenstraße 9, 40474, Duesseldorf, Germany
| | - Thomas Czihal
- Zentralinstitut für die Kassenärztliche Versorgung in der Bundesrepublik Deutschland, Salzufer 8, 10587, Berlin, Germany
| | - Dominik von Stillfried
- Zentralinstitut für die Kassenärztliche Versorgung in der Bundesrepublik Deutschland, Salzufer 8, 10587, Berlin, Germany
| | - Stefan Wilm
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Leonie Sundmacher
- Chair of Health Economics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany.,Department for Health Services Management, Ludwig-Maximilian-University Munich, Munich, Germany
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Chima S, Martinez-Gutierrez J, Hunter B, Manski-Nankervis JA, Emery J. Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study. JMIR Form Res 2022; 6:e39277. [PMID: 35925656 PMCID: PMC9389376 DOI: 10.2196/39277] [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: 05/12/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background The most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority. Objective This study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial. Methods GPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach. Results A total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs’ perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients’ worries. Conclusions There was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.
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Affiliation(s)
- Sophie Chima
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Australia
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Javiera Martinez-Gutierrez
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Australia
- Department of General Practice, University of Melbourne, Melbourne, Australia
- Department of Family Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Barbara Hunter
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | | | - Jon Emery
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Australia
- Department of General Practice, University of Melbourne, Melbourne, Australia
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Ye P, Jin Y, Er Y, Yin X, Yao Y, Li B, Zhang J, Ivers R, Keay L, Duan L, Tian M. Perceptions of Facilitators and Barriers to Implementation of Falls Prevention Programs in Primary Health Care Settings in China. JAMA Netw Open 2022; 5:e2228960. [PMID: 36018587 PMCID: PMC9419020 DOI: 10.1001/jamanetworkopen.2022.28960] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Falls have become a major public health issue in China with population aging. Although falls prevention for older community-dwelling people has been included in the National Essential Public Health Service Package since 2009, there is limited understanding of the implementation of this program. OBJECTIVE To identify the associated factors and provide recommendations to inform the better implementation of falls prevention in the Chinese primary health care system. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted in 3 purposively selected cities in China from March 1 to June 7, 2021. Health administrators from the local health commission or bureau, staff members from local Centers for Disease Control and Prevention and primary health care facilities and community-dwelling older people were recruited, using a combination of purposive sampling and snowball sampling. MAIN OUTCOMES AND MEASURES In-depth interviews were conducted with health administrators and focus groups with other participants. Data analysis followed the guidance of the Consolidated Framework for Implementation Research. Study outcomes included facilitators and barriers of implementing falls prevention for older people in the Chinese primary health care settings. A framework with recommendations was developed to inform the future intervention implementation. RESULTS Among a total of 130 participants interviewed, 77 (59.2%) were female and the mean (SD) age was 47.4 (16.7) years. Clear recognition of the challenges and benefits of falls prevention, adaptive regionally tailored guidance plans, and continuous governmental policy and financial support were the major facilitators, whereas the major barriers consisted of insufficient confidence in delivering interventions and poor understanding of the falls burden, low recognition of the importance of falls prevention, limited multisectoral collaboration, and weak financial incentives. A 7-strategy embedded framework-including data-driven surveillance, audit and feedback, implementation strategy, workforce strengthening, community empowerment, internal services integration, and external enabling environment-was developed to foster successful implementation. CONCLUSIONS AND RELEVANCE This qualitative study identified major facilitators and barriers to the implementation of falls prevention for older people at the primary care level, which have the potential to contribute to better implementation of falls prevention for older people in the Chinese primary health care system.
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Affiliation(s)
- Pengpeng Ye
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Ye Jin
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Yuliang Er
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Xuejun Yin
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Yao Yao
- China Centre for Health Development Studies, Peking University, Beijing, China
| | - Bingqin Li
- Social Policy Research Centre, UNSW Sydney, Sydney, Australia
| | - Jing Zhang
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Rebecca Ivers
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Lisa Keay
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Leilei Duan
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
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188
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Chan TM, Dowling S, Tastad K, Chin A, Thoma B. Integrating training, practice, and reflection within a new model for Canadian medical licensure: a concept paper prepared for the Medical Council of Canada. CANADIAN MEDICAL EDUCATION JOURNAL 2022; 13:68-81. [PMID: 36091730 PMCID: PMC9441128 DOI: 10.36834/cmej.73717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In 2020 the Medical Council of Canada created a task force to make recommendations on the modernization of its practices for granting licensure to medical trainees. This task force solicited papers on this topic from subject matter experts. As outlined within this Concept Paper, our proposal would shift licensure away from the traditional focus on high-stakes summative exams in a way that integrates training, clinical practice, and reflection. Specifically, we propose a model of graduated licensure that would have three stages including: a trainee license for trainees that have demonstrated adequate medical knowledge to begin training as a closely supervised resident, a transition to practice license for trainees that have compiled a reflective educational portfolio demonstrating the clinical competence required to begin independent practice with limitations and support, and a fully independent license for unsupervised practice for attendings that have demonstrated competence through a reflective portfolio of clinical analytics. This proposal was reviewed by a diverse group of 30 trainees, practitioners, and administrators in medical education. Their feedback was analyzed and summarized to provide an overview of the likely reception that this proposal would receive from the medical education community.
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Affiliation(s)
- Teresa M Chan
- Division of Emergency Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University
- Division of Education & Innovation, Department of Medicine
- Faculty of Health Sciences, McMaster University; McMaster Education Research, Innovation, and Theory (MERIT) program
- Office of Continuing Professional Development; Faculty of Health Sciences, McMaster University
| | - Shawn Dowling
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary
| | - Kara Tastad
- Royal College Emergency Medicine Training Program, University of Toronto
| | - Alvin Chin
- Division of Emergency Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University
| | - Brent Thoma
- Department of Emergency Medicine, University of Saskatchewan
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Benbassat J, Baumal R, Cohen R. Quality Assurance of Undergraduate Medical Education in Israel by Continuous Monitoring and Prioritization of the Accreditation Standards. Rambam Maimonides Med J 2022; 13:RMMJ.10480. [PMID: 35921485 PMCID: PMC9345766 DOI: 10.5041/rmmj.10480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
External accreditation reviews of undergraduate medical curricula play an important role in their quality assurance. However, these reviews occur only at 4-10-year intervals and are not optimal for the immediate identification of problems related to teaching. Therefore, the Standards of Medical Education in Israel require medical schools to engage in continuous, ongoing monitoring of their teaching programs for compliance with accreditation standards. In this paper, we propose the following: (1) this monitoring be assigned to independent medical education units (MEUs), rather than to an infrastructure of the dean's office, and such MEUs to be part of the school governance and draw their authority from university institutions; and (2) the differences in the importance of the accreditation standards be addressed by discerning between the "most important" standards that have been shown to improve student well-being and/or patient health outcomes; "important" standards associated with student learning and/or performance; "possibly important" standards with face validity or conflicting evidence for validity; and "least important" standards that may lead to undesirable consequences. According to this proposal, MEUs will evolve into entities dedicated to ongoing monitoring of the education program for compliance with accreditation standards, with an authority to implement interventions. Hopefully, this will provide MEUs and faculty with the common purpose of meeting accreditation requirements, and an agreed-upon prioritization of accreditation standards will improve their communication and recommendations to faculty.
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Affiliation(s)
- Jochanan Benbassat
- Department of Medicine (retired), Hadassah—Hebrew University Medical Centre, Jerusalem, Israel
- To whom correspondence should be addressed. E-mail:
| | - Reuben Baumal
- Department of Laboratory Medicine and Pathobiology (retired), University of Toronto, Toronto, Ontario, Canada
| | - Robert Cohen
- Center of Medical Education (retired), Hebrew University—Hadassah Faculty of Medicine, Jerusalem, Israel
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190
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Cohen SR, Baayd J, García G, Quade C, Gero A, Ekey M, Poggio C, Simmons R. Facility-based simulation as a programmatic tool for implementing a statewide contraceptive initiative. BMC Health Serv Res 2022; 22:965. [PMID: 35906656 PMCID: PMC9335456 DOI: 10.1186/s12913-022-08332-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assessing implementation fidelity is highly recommended, but successful approaches can be challenging. Family Planning Elevated (FPE) is a statewide contraceptive initiative which partnered with 28 health clinics across Utah. To assess implementation fidelity, we developed in-situ high-fidelity simulation training to both determine clinic adherence to FPE and offer education to implementing teams. This study aimed to develop, pilot, and assess the use of simulation as a tool for measuring implementation fidelity. METHODS We developed two simulation scenarios to determine implementation fidelity: one scenario wherein a client is seeking a new method of contraception and another in which the same client has returned to discontinue the method. Both simulations contained multiple aspects of program implementation (e.g., determining program eligibility). We then offered simulations to all FPE partner organizations. To assess simulation training as a tool for determining implementation fidelity, we developed strategies aligned with each aspect of an adapted RE-AIM framework, including pre-post surveys, acceptability and self-efficacy testing, a checklist for programmatic adherence, field notes, action planning and analysis of monitoring data. RESULTS Fifteen clinical sites and 71 team members participated in the in-situ simulations. Assessment of the checklist showed that 90% of the clinics successfully demonstrated key program components, including person-centered counseling techniques such as sitting at the patient's level (95.8%); asking open-ended questions (100%); and explaining how to use the contraceptive method selected (91.7%). More than half of clinics fell short in programmatic areas including: confirmation that the FPE program covered same-day intrauterine device insertion (54.2%), and education on health risks associated with the selected contraceptive method (58.3%). After simulation, participants reported improved knowledge of how FPE works (p = < 0.001), increased ability to identify FPE-eligible clients (p = 0.02) and heightened self-efficacy in helping clients select a method (p = 0.03). Participants were satisfied with the simulations, with most (84.1%) reporting that the simulation exceeded their expectations. CONCLUSIONS Highly-realistic in-situ family planning simulations are acceptable to participants, positively change knowledge and clinical team confidence, and can identify systems gaps in clinical care and program implementation. Simulation offers a reciprocal way of monitoring implementation fidelity of a family planning access initiative. TRIAL REGISTRATION This project was determined to be exempt by the IRB of the University of Utah, the larger Family Planning Elevated program under which this pilot study was nested is registered at ClinicalTrials.gov Identifier: NCT03877757 .
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Affiliation(s)
- Susanna R Cohen
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - Jami Baayd
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Gabriela García
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Caitlin Quade
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Alexandra Gero
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Madison Ekey
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Catherine Poggio
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Rebecca Simmons
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
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Gutman A, Harty T, O'Donoghue K, Greene R, Leitao S. Perinatal mortality audits and reporting of perinatal deaths: systematic review of outcomes and barriers. J Perinat Med 2022; 50:684-712. [PMID: 35086187 DOI: 10.1515/jpm-2021-0363] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/21/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Perinatal deaths are a devastating experience for all families and healthcare professionals involved. Audit of perinatal mortality (PNM) is essential to better understand the factors associated with perinatal death, to identify key deficiencies in healthcare provision and should be utilised to improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs. CONTENT We searched the PubMed, EMBASE and EBSCO host, including Medline, Academic Search Complete and CINAHL Plus databases for articles that were published from 1st January 2000. Articles evaluating perinatal mortality audits or audit implementation, identifying risk or care factors of perinatal mortality through audits, in middle and/or high-income countries were considered for inclusion in this review. Twenty articles met inclusion criteria. Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training were highlighted as barriers to PNM reporting and audit implementation. Failure in timely detection and management of antenatal maternal and fetal conditions and late presentation or failure to escalate care were the most common substandard care factors identified through audit. Overall, recommendations for perinatal audit focused on standardised audit tools and training of staff. Overall, the implementation of audit recommendations remains unclear. SUMMARY This review highlights barriers to audit practices and emphasises the need for adequately trained staff to participate in regular audit that is standardised and thorough. To achieve the goal of reducing PNM, it is crucial that the audit cycle is completed with continuous re-evaluation of recommended changes.
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Affiliation(s)
- Arlene Gutman
- School of Medicine and Health, University College Cork, Cork, Ireland.,Pregnancy Loss Research Group (PLRG), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Tommy Harty
- School of Medicine and Health, University College Cork, Cork, Ireland.,Cork University Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group (PLRG), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland.,Cork University Maternity Hospital, Cork, Ireland.,The Irish Centre for Maternal and Child Health Research (INFANT), University College Cork, Cork, Ireland
| | - Richard Greene
- Department of Obstetrics and Gynaecology, School of Medicine and Health, University College Cork, Cork, Ireland.,Cork University Maternity Hospital, Cork, Ireland.,National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - Sara Leitao
- Department of Obstetrics and Gynaecology, School of Medicine and Health, University College Cork, Cork, Ireland.,Pregnancy Loss Research Group (PLRG), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland.,National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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Doherty E, Wiggers J, Nathan N, Hall A, Wolfenden L, Tully B, Elliott EJ, Attia J, Dunlop AJ, Symonds I, Tsang TW, Reeves P, McFadyen T, Wynne O, Kingsland M. Iterative delivery of an implementation support package to increase and sustain the routine provision of antenatal care addressing alcohol consumption during pregnancy: study protocol for a stepped-wedge cluster trial. BMJ Open 2022; 12:e063486. [PMID: 35882461 PMCID: PMC9330336 DOI: 10.1136/bmjopen-2022-063486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/14/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Antenatal care addressing alcohol consumption during pregnancy is not routinely delivered in maternity services. Although a number of implementation trials have reported significant increases in such care, the majority of women still did not receive all recommended care elements, and improvements dissipated over time. This study aims to assess the effectiveness of an iteratively developed and delivered implementation support package in: (1) increasing the proportion of pregnant women who receive antenatal care addressing alcohol consumption and (2) sustaining the rate of care over time. METHODS AND ANALYSIS A stepped-wedge cluster trial will be conducted as a second phase of a previous trial. All public maternity services within three sectors of a local health district in Australia will receive an implementation support package that was developed based on an assessment of outcomes and learnings following the initial trial. The package will consist of evidence-based strategies to support increases in care provision (remind clinicians; facilitation; conduct educational meetings) and sustainment (develop a formal implementation blueprint; purposely re-examine the implementation; conduct ongoing training). Measurement of outcomes will occur via surveys with women who attend antenatal appointments each week. Primary outcomes will be the proportion of women who report being asked about alcohol consumption at subsequent antenatal appointments; and receiving complete care (advice and referral) relative to alcohol risk at initial and subsequent antenatal appointments. Economic and process evaluation measures will also be reported. ETHICS AND DISSEMINATION Ethical approval was obtained through the Hunter New England (16/11/16/4.07, 16/10/19/5.15) and University of Newcastle Human Research Ethics Committees (H-2017-0032, H-2016-0422) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health service decision makers to inform the feasibility of conducting additional cycles to further improve antenatal care addressing alcohol consumption as well as at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trials Registry (ACTRN12622000295741).
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Affiliation(s)
- Emma Doherty
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - John Wiggers
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Nicole Nathan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Alix Hall
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Belinda Tully
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Elizabeth J Elliott
- Faculty of Medicine and Health and Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Children's Hospital Network, Kids' Research Institute, Westmead, New South Wales, Australia
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Clinical Research Design and Statistics, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Adrian John Dunlop
- Drug and Alcohol Clinical Services Research, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Ian Symonds
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Tracey W Tsang
- Faculty of Medicine and Health and Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Children's Hospital Network, Kids' Research Institute, Westmead, New South Wales, Australia
| | - Penny Reeves
- Health Research Economics, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Tameka McFadyen
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- Thurru Indigenous Health Unit, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Olivia Wynne
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Melanie Kingsland
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
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Ersek M, Sales A, Keddem S, Ayele R, Haverhals LM, Magid KH, Kononowech J, Murray A, Carpenter JG, Foglia MB, Potter L, McKenzie J, Davis D, Levy C. Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration. Implement Sci Commun 2022; 3:78. [PMID: 35859140 PMCID: PMC9296899 DOI: 10.1186/s43058-022-00321-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. METHODS PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. DISCUSSION The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.
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Affiliation(s)
- Mary Ersek
- Center for Health Equity and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Annex Suite 203, Philadelphia, PA, 19104, USA. .,University of Pennsylvania Schools of Nursing and Medicine, Philadelphia, PA, USA.
| | - Anne Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Shimrit Keddem
- Center for Health Equity and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Annex Suite 203, Philadelphia, PA, 19104, USA.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Roman Ayele
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Leah M Haverhals
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kate H Magid
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Andrew Murray
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Joan G Carpenter
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,University of Maryland School of Nursing, Baltimore, MD, USA
| | - Mary Beth Foglia
- VA National Center for Ethics in Health Care, Washington, D.C., USA.,Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lucinda Potter
- VA National Center for Ethics in Health Care, Washington, D.C., USA
| | - Jennifer McKenzie
- VA Purchased Long-Term Services and Supports, Geriatrics and Extended Care, D, Washington, .C, USA
| | - Darlene Davis
- Home-Based Primary Care Program, Office of Geriatrics and Extended Care, Washington, D.C., USA
| | - Cari Levy
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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194
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Affiliation(s)
| | - Alexander Singer
- Max Rady College of Medicine, Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Nita G Forouhi
- Medical Research Council Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Wendy Levinson
- Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Patey AM, Fontaine G, Francis JJ, McCleary N, Presseau J, Grimshaw JM. Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions. Psychol Health 2022; 38:766-794. [PMID: 35839082 DOI: 10.1080/08870446.2022.2100887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Healthcare professional (HCP) behaviours are actions performed by individuals and teams for varying and often complex patient needs. However, gaps exist between evidence-informed care behaviours and the care provided. Implementation science seeks to develop generalizable principles and approaches to investigate and address care gaps, supporting HCP behaviour change while building a cumulative science. We highlight theory-informed approaches for defining HCP behaviour and investigating the prevalence of evidence-based care and known correlates and interventions to change professional practice. Behavioural sciences can be applied to develop implementation strategies to support HCP behaviour change and provide valid, reliable tools to evaluate these strategies. There are thousands of different behaviours performed by different HCPs across many contexts, requiring different implementation approaches. HCP behaviours can include activities related to promoting health and preventing illness, assessing and diagnosing illnesses, providing treatments, managing health conditions, managing the healthcare system and building therapeutic alliances. The key challenge is optimising behaviour change interventions that address barriers to and enablers of recommended practice. HCP behaviours may be determined by, but not limited to, Knowledge, Social influences, Intention, Emotions and Goals. Understanding HCP behaviour change is a critical to ensuring advances in health psychology are applied to maximize population health.
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Affiliation(s)
- Andrea M. Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jillian J. Francis
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicola McCleary
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin Presseau
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeremy M. Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Long D, Gibbons K, Dow B, Best J, Webb KL, Liley HG, Stocker C, Thoms D, Schlapbach LJ, Wharton C, Lister P, Matuschka L, Castillo MI, Tyack Z, Bora S. Effectiveness-implementation hybrid-2 randomised trial of a collaborative Shared Care Model for Detecting Neurodevelopmental Impairments after Critical Illness in Young Children (DAISY): pilot study protocol. BMJ Open 2022; 12:e060714. [PMID: 35840297 PMCID: PMC9295674 DOI: 10.1136/bmjopen-2021-060714] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/04/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION In Australia, while paediatric intensive care unit (PICU) mortality has dropped to 2.2%, one in three survivors experience long-term neurodevelopmental impairment, limiting their life-course opportunities. Unlike other high-risk paediatric populations, standardised routine neurodevelopmental follow-up of PICU survivors is rare, and there is limited knowledge regarding the best methods. The present study intends to pilot a combined multidisciplinary, online screening platform and general practitioner (GP) shared care neurodevelopmental follow-up model to determine feasibility of a larger, future study. We will also assess the difference between neurodevelopmental vulnerability and parental stress in two intervention groups and the impact of child, parent, sociodemographic and illness/treatment risk factors on child and parent outcomes. METHODS AND ANALYSIS Single-centre randomised effectiveness-implementation (hybrid-2 design) pilot trial for parents of children aged ≥2 months and <4 years discharged from PICU after critical illness or injury. One intervention group will receive 6 months of collaborative shared care follow-up with GPs (supported by online outcome monitoring), and the other will be offered self-directed screening and education about post-intensive care syndrome and child development. Participants will be followed up at 1, 3 and 6 months post-PICU discharge. The primary outcome is feasibility. Secondary outcomes include neurodevelopmental vulnerability and parental stress. An implementation evaluation will analyse barriers to and facilitators of the intervention. ETHICS AND DISSEMINATION The study is expected to lead to a full trial, which will provide much-needed guidance about the clinical effectiveness and implementation of follow-up models of care for children after critical illness or injury. The Children's Health Queensland Human Research Ethics Committee approved this study. Dissemination of the outcomes of the study is expected via publication in a peer-reviewed journal, presentation at relevant conferences, and via social media, podcast presentations and open-access medical education resources. REGISTRATION DETAILS The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as 'Pilot testing of a collaborative Shared Care Model for Detecting Neurodevelopmental Impairments after Critical Illness in Young Children' (the DAISY Pilot Study). TRIAL REGISTRATION NUMBER ACTRN12621000799853.
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Affiliation(s)
- Debbie Long
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Belinda Dow
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - James Best
- General Practice, Junction Street Family Practice, Nowra, New South Wales, Australia
| | - Kerri-Lyn Webb
- Developmental Paediatrics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Helen G Liley
- Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
- Newborn Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia
| | - Christian Stocker
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Debra Thoms
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Faculty of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - Carolyn Wharton
- Consumer Representative, Health Consumers Queensland, Brisbane, Queensland, Australia
| | - Paula Lister
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Critical Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Lori Matuschka
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Maria Isabel Castillo
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Zephanie Tyack
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Samudragupta Bora
- Mothers, Babies and Women's Health Program, Mater Research Institute, Faculty of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
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197
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Yigzaw KY, Chomutare T, Wynn R, Berntsen GKR, Bellika JG. A Privacy-Preserving Audit and Feedback System for the Antibiotic Prescribing of General Practitioners: Survey Study. JMIR Form Res 2022; 6:e31650. [PMID: 35830221 PMCID: PMC9330202 DOI: 10.2196/31650] [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: 07/01/2021] [Revised: 03/21/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Antibiotic resistance is a worldwide public health problem that is accelerated by the misuse and overuse of antibiotics. Studies have shown that audits and feedback enable clinicians to compare their personal clinical performance with that of their peers and are effective in reducing the inappropriate prescribing of antibiotics. However, privacy concerns make audits and feedback hard to implement in clinical settings. To solve this problem, we developed a privacy-preserving audit and feedback (A&F) system. Objective This study aims to evaluate a privacy-preserving A&F system in clinical settings. Methods A privacy-preserving A&F system was deployed at three primary care practices in Norway to generate feedback for 20 general practitioners (GPs) on their prescribing of antibiotics for selected respiratory tract infections. The GPs were asked to participate in a survey shortly after using the system. Results A total of 14 GPs responded to the questionnaire, representing a 70% (14/20) response rate. The participants were generally satisfied with the usefulness of the feedback and the comparisons with peers, as well as the protection of privacy. The majority of the GPs (9/14, 64%) valued the protection of their own privacy as well as that of their patients. Conclusions The system overcomes important privacy and scaling challenges that are commonly associated with the secondary use of electronic health record data and has the potential to improve antibiotic prescribing behavior; however, further study is required to assess its actual effect.
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Affiliation(s)
| | - Taridzo Chomutare
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - Rolf Wynn
- Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Divison of Substance Use and Mental Health, University Hospital of North Norway, Tromsø, Norway
| | - Gro Karine Rosvold Berntsen
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Johan Gustav Bellika
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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198
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Sykes M, O'Halloran E, Mahon L, McSharry J, Allan L, Thomson R, Finch T, Kolehmainen N. Enhancing national audit through addressing the quality improvement capabilities of feedback recipients: a multi-phase intervention development study. Pilot Feasibility Stud 2022; 8:143. [PMID: 35804468 PMCID: PMC9264699 DOI: 10.1186/s40814-022-01099-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/20/2022] [Indexed: 12/11/2022] Open
Abstract
Background National audits are a common, but variably effective, intervention to improve services. This study aimed to design an intervention to increase the effectiveness of national audit. Methods We used interviews, documentary analysis, observations, co-design and stakeholder engagement methods. The intervention was described in an intervention manual and illustrated using a logic model. Phase 1 described the current hospital response to a national audit. Phase 2 identified potential enhancements. Phase 3 developed a strategy to implement the enhancements. Phase 4 explored the feasibility of the intervention alongside the National Audit of Dementia and refined the intervention. Phase 5 adapted the intervention to a second national audit (National Diabetes Audit). Phase 6 explored the feasibility and fidelity of the intervention alongside the National Diabetes Audit and used the findings to further refine the intervention. Results The developed intervention is a quality improvement collaborative (QIC), containing virtual educational workshop, virtual outreach for local team leads and virtual facilitation of a learning collaborative delivered after feedback has been received. The QIC aims to support national audit recipients to undertake improvement actions tailored to their local context. The target audience is clinical and clinical governance leaders. We found that actions from national audit were constrained by what the clinical lead perceived they deliver personally, these actions were not aligned to identified influences upon performance. We found that the hospital response could be enhanced by targeting low baseline performance, identifying and addressing influences upon to performance, developing trust and credibility, addressing recipient priorities, presenting meaningful comparisons, developing a conceptual model, involving stakeholders and considering the opportunity cost. Phase 3 found that an educational workshop and outreach strategy could support implementation of the enhancements through developing coherence and cognitive participation. We found feasibility could be increased by revising the content, re-naming the intervention, amending activities to address time commitment, incorporating a more structured analysis of influences, supporting collaboration and developing local feedback mechanisms. Phase 5 found adaptation to a second national audit involved reflecting differences in the clinical topic, context and contractual requirements. We found that the behaviour change techniques identified in the manual were delivered by facilitators. Participants reported positive attitudes towards the intervention and that the intervention was appropriate. Conclusions The QIC supports local teams to tailor their actions to local context and develop change commitment. Future work will evaluate the effectiveness of the intervention as an adjunct to the National Diabetes Audit.
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Affiliation(s)
- Michael Sykes
- Northumbria University, Newcastle upon Tyne, NE7 7XA, UK.
| | - Elaine O'Halloran
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Lucy Mahon
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Jenny McSharry
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Louise Allan
- University of Exeter, South Cloisters, St. Luke's Campus, Heavitree Road, Exeter, UK
| | - Richard Thomson
- Newcastle University, Richardson Road, Newcastle upon Tyne, UK
| | - Tracy Finch
- Northumbria University, Newcastle upon Tyne, NE7 7XA, UK
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199
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Cheng H, McGovern MP, Garneau HC, Hurley B, Fisher T, Copeland M, Almirall D. Expanding access to medications for opioid use disorder in primary care clinics: an evaluation of common implementation strategies and outcomes. Implement Sci Commun 2022; 3:72. [PMID: 35794653 PMCID: PMC9258188 DOI: 10.1186/s43058-022-00306-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To combat the opioid epidemic in the USA, unprecedented federal funding has been directed to states and territories to expand access to prevention, overdose rescue, and medications for opioid use disorder (MOUD). Similar to other states, California rapidly allocated these funds to increase reach and adoption of MOUD in safety-net, primary care settings such as Federally Qualified Health Centers. Typical of current real-world implementation endeavors, a package of four implementation strategies was offered to all clinics. The present study examines (i) the pre-post effect of the package of strategies, (ii) whether/how this effect differed between new (start-up) versus more established (scale-up) MOUD practices, and (iii) the effect of clinic engagement with each of the four implementation strategies. METHODS Forty-one primary care clinics were offered access to four implementation strategies: (1) Enhanced Monitoring and Feedback, (2) Learning Collaboratives, (3) External Facilitation, and (4) Didactic Webinars. Using linear mixed effects models, RE-AIM guided outcomes of reach, adoption, and implementation quality were assessed at baseline and at 9 months follow-up. RESULTS Of the 41 clinics, 25 (61%) were at MOUD start-up and 16 (39%) were at scale-up phases. Pre-post difference was observed for the primary outcome of percent of patient prescribed MOUD (reach) (βtime = 3.99; 0.73 to 7.26; p = 0.02). The largest magnitude of change occurred in implementation quality (ES = 0.68; 95% CI = 0.66 to 0.70). Baseline MOUD capability moderated the change in reach (start-ups 22.60%, 95% CI = 16.05 to 29.15; scale-ups -4.63%, 95% CI = -7.87 to -1.38). Improvement in adoption and implementation quality were moderately associated with early prescriber engagement in Learning Collaboratives (adoption: ES = 0.61; 95% CI = 0.25 to 0.96; implementation quality: ES = 0.55; 95% CI = 0.41 to 0.69). Improvement in adoption was also associated with early prescriber engagement in Didactic Webinars (adoption: ES = 0.61; 95% CI = 0.20 to 1.05). CONCLUSIONS Rather than providing an all-clinics-get-all-components package of implementation strategies, these data suggest that it may be more efficient and effective to tailor the provision of implementation strategies based on the needs of clinic. Future implementation endeavors could benefit from (i) greater precision in the provision of implementation strategies based on contextual determinants, and (ii) the inclusion of strategies targeting engagement.
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Affiliation(s)
- Hannah Cheng
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Mark P McGovern
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Hélène Chokron Garneau
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Brian Hurley
- Los Angeles County Department of Public Health, Los Angeles, CA, USA
- Department of Family Medicine, University of California, Los Angeles, CA, USA
| | | | | | - Daniel Almirall
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- Department of Statistics, University of Michigan, Ann Arbor, MI, USA
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200
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McEvoy MD, Dear ML, Buie R, Edwards DA, Barrett TW, Allen B, Robertson AC, Fowler LC, Hennessy C, Miller BM, Garvey KV, Bland RP, Fleming GM, Moore D, Rice TW, Bernard GR, Lindsell CJ. Effect of Smartphone App-Based Education on Clinician Prescribing Habits in a Learning Health Care System: A Randomized Cluster Crossover Trial. JAMA Netw Open 2022; 5:e2223099. [PMID: 35881398 PMCID: PMC9327570 DOI: 10.1001/jamanetworkopen.2022.23099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. OBJECTIVE To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. DESIGN, SETTING, AND PARTICIPANTS A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. INTERVENTIONS All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. MAIN OUTCOMES AND MEASURES The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. RESULTS A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03771482.
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Affiliation(s)
- Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- Episodes of Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy C. Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bonnie M. Miller
- Department of the Office of Health Sciences Education, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kim V. Garvey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P. Bland
- Department of HealthIT Architecture and Integration, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Geoffrey M. Fleming
- Department of Pediatrics, Vanderbilt Children’s Hospital, Nashville, Tennessee
| | - Don Moore
- Professor of Medical Education and Administration, Emeritus, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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