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Slattery C, Freund M, Gillham K, Knight J, Wolfenden L, Bisquera A, Wiggers J. Increasing smoking cessation care across a network of hospitals: an implementation study. Implement Sci 2016; 11:28. [PMID: 26927023 PMCID: PMC4772530 DOI: 10.1186/s13012-016-0390-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 02/23/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite clinical practice guidelines recommending the provision of smoking cessation care to all smokers in hospital, the provision of such care can be sub-optimal. A study was conducted to assess the impact of an intervention on the provision of smoking cessation care to nicotine-dependent smokers across a network of hospitals. METHODS A 4-year interrupted time series study was undertaken in a single health district in New South Wales, Australia. A multi-component intervention was implemented over a 2-year period in all 37 public general hospitals. Outcome data were collected from eight randomly selected hospitals via medical record audit. Logistic regression analyses assessed differences between baseline, intervention and follow-up periods in the provision of seven measures of care: brief advice, offer and provision of inpatient and discharge nicotine replacement therapy, and offer and acceptance of referral to a Quitline. RESULTS Approximately 164,250 patients were discharged from the hospitals during the study, 16 % of whom were smokers. Of the selected smokers, 56.12 % (n = 2072) were nicotine-dependent. The prevalence of smoking cessation care increased significantly for all seven measures between baseline and intervention periods, and for six of the seven measures between the baseline and follow-up periods. The odds of receiving care at follow-up were between 1.7 (CI 1.18-2.58, p = 0.0004) and 6.2 (CI 2.84-13.85, p < 0.0001) times greater than at baseline. At follow-up, 53, 16 and 7 of smokers were offered inpatient NRT, discharge NRT and a Quitline referral, respectively. CONCLUSIONS Significant gains in the provision of smoking cessation care were indicated. However, at best, slightly more than half of the patients received smoking cessation care. Additional care enhancement strategies are required if all smokers are to obtain the intended benefits of smoking cessation care guidelines.
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Affiliation(s)
- Carolyn Slattery
- Population Health, Hunter New England Local Health District, Booth Building, Wallsend Health Services, Longworth Avenue, Wallsend, NSW 2287 Australia
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
| | - Megan Freund
- Population Health, Hunter New England Local Health District, Booth Building, Wallsend Health Services, Longworth Avenue, Wallsend, NSW 2287 Australia
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308 Australia
| | - Karen Gillham
- Population Health, Hunter New England Local Health District, Booth Building, Wallsend Health Services, Longworth Avenue, Wallsend, NSW 2287 Australia
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
| | - Jenny Knight
- Population Health, Hunter New England Local Health District, Booth Building, Wallsend Health Services, Longworth Avenue, Wallsend, NSW 2287 Australia
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
| | - Luke Wolfenden
- Population Health, Hunter New England Local Health District, Booth Building, Wallsend Health Services, Longworth Avenue, Wallsend, NSW 2287 Australia
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308 Australia
| | - Alessandra Bisquera
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
| | - John Wiggers
- Population Health, Hunter New England Local Health District, Booth Building, Wallsend Health Services, Longworth Avenue, Wallsend, NSW 2287 Australia
- Hunter Medical Research Institute, Clinical Research Centre, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305 Australia
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308 Australia
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152
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Bester N, Di Vito-Smith M, McGarry T, Riffkin M, Kaehler S, Pilot R, Bwire R. The Effectiveness of an Educational Brochure as a Risk Minimization Activity to Communicate Important Rare Adverse Events to Health-Care Professionals. Adv Ther 2016; 33:167-77. [PMID: 26801772 PMCID: PMC4769727 DOI: 10.1007/s12325-016-0284-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Educational brochures are an important tool for communicating risk to health-care professionals. It is important to evaluate the impact of any risk minimization tool to understand the effectiveness of the strategy. The objective of this study was to assess the effectiveness (i.e., respondents' awareness and understanding of the communication) of a targeted educational brochure distributed to health-care professionals (HCPs) as a risk minimization strategy for the communication of new rare and important adverse events (AEs). METHODS A prospective, non-interventional, online survey was performed following distribution of a specifically designed brochure highlighting new and important adverse events to a targeted HCP population, consisting of known users of the target medicine, as represented by a commercial database. Predefined multiple-choice survey questions assessed overall HCP awareness of the brochure and understanding and retention of information in those HCPs who reported receiving the brochure. RESULTS The educational brochure was sent to a total of 565 HCPs; 121 (21.4%) responded to the survey. The majority of respondents (95.0%) had previously prescribed or dispensed the target medicine. In all, 88 (72.7%) respondents said they had received the educational brochure, of whom 95.5% stated they had at least scanned the main points. More participants who had received the brochure (86.4% to 96.6%) answered the five individual survey questions correctly compared with those who did not (51.5% to 97.0%); this was significant for four out of five questions (P ≤ 0.005). Significantly more HCPs who received the brochure achieved the predefined pass rate (at least four of five questions answered correctly) compared with HCPs who did not receive the brochure (93.2% vs 57.6%, respectively; P = 0.000003). CONCLUSIONS Distribution of targeted educational brochures may be an effective risk minimization strategy to raise HCP awareness of new rare and important AEs; educational brochures may also be an effective channel for sharing information on how these AEs can be best managed and on the importance and means of reporting AEs. FUNDING Celgene Pty Ltd, Melbourne, Australia.
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153
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Hsiao JL, Chen RF. Critical factors influencing physicians' intention to use computerized clinical practice guidelines: an integrative model of activity theory and the technology acceptance model. BMC Med Inform Decis Mak 2016; 16:3. [PMID: 26772169 PMCID: PMC4715302 DOI: 10.1186/s12911-016-0241-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 01/08/2016] [Indexed: 01/22/2023] Open
Abstract
Background With the widespread use of information communication technologies, computerized clinical practice guidelines are developed and considered as effective decision supporting tools in assisting the processes of clinical activities. However, the development of computerized clinical practice guidelines in Taiwan is still at the early stage and acceptance level among major users (physicians) of computerized clinical practice guidelines is not satisfactory. This study aims to investigate critical factors influencing physicians’ intention to computerized clinical practice guideline use through an integrative model of activity theory and the technology acceptance model. Methods The survey methodology was employed to collect data from physicians of the investigated hospitals that have implemented computerized clinical practice guidelines. A total of 505 questionnaires were sent out, with 238 completed copies returned, indicating a valid response rate of 47.1 %. The collected data was then analyzed by structural equation modeling technique. Results The results showed that attitudes toward using computerized clinical practice guidelines (γ = 0.451, p < 0.001), organizational support (γ = 0.285, p < 0.001), perceived usefulness of computerized clinical practice guidelines (γ = 0.219, p < 0.05), and social influence (γ = 0.213, p < 0.05) were critical factors influencing physicians’ intention to use computerized clinical practice guidelines, and these factors can explain 68.6 % of the variance in intention to use computerized clinical practice guidelines. Conclusions This study confirmed that some subject (human) factors, environment (organization) factors, tool (technology) factors mentioned in the activity theory should be carefully considered when introducing computerized clinical practice guidelines. Managers should pay much attention on those identified factors and provide adequate resources and incentives to help the promotion and use of computerized clinical practice guidelines. Through the appropriate use of computerized clinical practice guidelines, the clinical benefits, particularly in improving quality of care and facilitating the clinical processes, will be realized.
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Affiliation(s)
- Ju-Ling Hsiao
- Department of Hospital and Health Care Administration, Chia-Nan University of Pharmacy and Science, Tainan City, Taiwan R.O.C..
| | - Rai-Fu Chen
- Department of Information Management, Chia-Nan University of Pharmacy and Science, No.60, Sec. 1, Erren Rd., Rende Dist., Tainan City, 71710, Taiwan R.O.C..
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154
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Harris C, Garrubba M, Allen K, King R, Kelly C, Thiagarajan M, Castleman B, Ramsey W, Farjou D. Development, implementation and evaluation of an evidence-based program for introduction of new health technologies and clinical practices in a local healthcare setting. BMC Health Serv Res 2015; 15:575. [PMID: 26707549 PMCID: PMC4692064 DOI: 10.1186/s12913-015-1178-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/18/2015] [Indexed: 02/07/2023] Open
Abstract
Background This paper reports the process of establishing a transparent, accountable, evidence-based program for introduction of new technologies and clinical practices (TCPs) in a large Australian healthcare network. Many countries have robust evidence-based processes for assessment of new TCPs at national level. However many decisions are made by local health services where the resources and expertise to undertake health technology assessment (HTA) are limited and a lack of structure, process and transparency has been reported. Methods An evidence-based model for process change was used to establish the program. Evidence from research and local data, experience of health service staff and consumer perspectives were incorporated at each of four steps: identifying the need for change, developing a proposal, implementation and evaluation. Checklists assessing characteristics of success, factors for sustainability and barriers and enablers were applied and implementation strategies were based on these findings. Quantitative and qualitative methods were used for process and outcome evaluation. An action research approach underpinned ongoing refinement to systems, processes and resources. Results A Best Practice Guide developed from the literature and stakeholder consultation identified seven program components: Governance, Decision-Making, Application Process, Monitoring and Reporting, Resources, Administration, and Evaluation and Quality Improvement. The aims of transparency and accountability were achieved. The processes are explicit, decisions published, outcomes recorded and activities reported. The aim of ascertaining rigorous evidence-based information for decision-making was not achieved in all cases. Applicants proposing new TCPs provided the evidence from research literature and local data however the information was often incorrect or inadequate, overestimating benefits and underestimating costs. Due to these limitations the initial application process was replaced by an Expression of Interest from applicants followed by a rigorous HTA by independent in-house experts. Conclusion The program is generalisable to most health care organisations. With one exception, the components would be achievable with minimal additional resources; the lack of skills and resources required for HTA will limit effective application in many settings. A toolkit containing details of the processes and sample materials is provided to facilitate replication or local adaptation by those wishing to establish a similar program. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1178-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia. .,Centre for Clinical Effectiveness, Monash Health, Victoria, Australia.
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Monash Health, Victoria, Australia.
| | - Kelly Allen
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia. .,Centre for Clinical Effectiveness, Monash Health, Victoria, Australia.
| | - Richard King
- Medicine Program, Monash Health, Victoria, Australia.
| | - Cate Kelly
- Medical Services, Alfred Health, Victoria, Australia.
| | | | | | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Victoria, Australia.
| | - Dina Farjou
- Centre for Clinical Effectiveness, Monash Health, Victoria, Australia.
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155
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Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews. BMJ Open 2015; 5:e009993. [PMID: 26700290 PMCID: PMC4691771 DOI: 10.1136/bmjopen-2015-009993] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. DESIGN Systematic review of reviews. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. DATA SYNTHESIS Extracted data were synthesised using a narrative approach. RESULTS 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2-9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. CONCLUSIONS There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO REGISTRATION NUMBER CRD42014009410.
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Affiliation(s)
- Rosa Lau
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Fiona Stevenson
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Scotland, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton,UK
| | - Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Nadeem Qureshi
- Division of Primary Care, University of Nottingham, Derby, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Elizabeth Murray
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
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156
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Leon N, Brady L, Kwamie A, Daniels K. Routine Health Information System (RHIS) interventions to improve health systems management. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd012012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Natalie Leon
- South African Medical Research Council; Health Systems Research Unit; Cape Town South Africa
| | - Leanne Brady
- School of Public Health and Family Medicine, University of Cape Town; Health Economics Unit, Health Policy and Systems Division; Cape Town South Africa
| | - Aku Kwamie
- School of Public Health, University of Ghana; Department of Health Policy, Planning and Management; Accra Ghana
| | - Karen Daniels
- South African Medical Research Council; Health Systems Research Unit; Cape Town South Africa
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157
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Grudniewicz A, Kealy R, Rodseth RN, Hamid J, Rudoler D, Straus SE. What is the effectiveness of printed educational materials on primary care physician knowledge, behaviour, and patient outcomes: a systematic review and meta-analyses. Implement Sci 2015; 10:164. [PMID: 26626547 PMCID: PMC4666153 DOI: 10.1186/s13012-015-0347-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/29/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Printed educational materials (PEMs) are commonly used simple interventions that can be used alone or with other interventions to disseminate clinical evidence. They have been shown to have a small effect on health professional behaviour. However, we do not know whether they are effective in primary care. We investigated whether PEMs improve primary care physician (PCP) knowledge, behaviour, and patient outcomes. METHODS We conducted a systematic review of PEMs developed for PCPs. Electronic databases were searched for randomized controlled trials, quasi randomized controlled trials, controlled before and after studies, and interrupted time series. We combined studies using meta-analyses when possible. Statistical heterogeneity was examined, and meta-analysis was performed using a random effects model when significant statistical heterogeneity was present and a fixed effects model otherwise. The template for intervention description and replication (TIDieR) checklist was used to assess the quality of intervention description. RESULTS Our search identified 12,439 studies and 40 studies met our inclusion criteria. We combined outcomes from 26 studies in eight meta-analyses. No significant effect was found on clinically important patient outcomes, physician behaviour, or physician cognition when PEMs were compared to usual care. In the 14 studies that could not be included in the meta-analyses, 14 of 71 outcomes were significantly improved following receipt of PEMs compared to usual care. Most studies lacked details needed to replicate the intervention. CONCLUSIONS PEMs were not effective at improving patient outcomes, knowledge, or behaviour of PCPs. Further trials should explore ways to optimize the intervention and provide detailed information on the design of the materials. PROTOCOL REGISTRATION PROSPERO, CRD42013004356.
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Affiliation(s)
- Agnes Grudniewicz
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 7th Floor, East Building, Toronto, Canada.
| | - Ryan Kealy
- Interactive Media Lab, Department of Mechanical and Industrial Engineering, University of Toronto, Bahen Centre for Information Technology, 40 St. George Street, Toronto, Canada.
| | - Reitze N Rodseth
- Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Nata, Pietermaritzburg, South Africa.
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Jemila Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 7th Floor, East Building, Toronto, Canada.
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - David Rudoler
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 7th Floor, East Building, Toronto, Canada.
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158
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Bussières AE, Terhorst L, Leach M, Stuber K, Evans R, Schneider MJ. Self-reported attitudes, skills and use of evidence-based practice among Canadian doctors of chiropractic: a national survey. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2015; 59:332-48. [PMID: 26816412 PMCID: PMC4711333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To identify Canadian chiropractors' attitudes, skills and use of evidence based practice (EBP), as well as their level of awareness of previously published chiropractic clinical practice guidelines (CPGs). METHODS 7,200 members of the Canadian Chiropractic Association were invited by e-mail to complete an online version of the Evidence Based practice Attitude & utilisation SurvEy (EBASE); a valid and reliable measure of participant attitudes, skills and use of EBP. RESULTS Questionnaires were completed by 554 respondents. Most respondents (>75%) held positive attitudes toward EBP. Over half indicated a high level of self-reported skills in EBP, and over 90% expressed an interest in improving these skills. A majority of respondents (65%) reported over half of their practice was based on evidence from clinical research, and only half (52%) agreed that chiropractic CPGs significantly impacted on their practice. CONCLUSIONS While most Canadian chiropractors held positive attitudes towards EBP, believed EBP was useful, and were interested in improving their skills in EBP, many did not use research evidence or CPGs to guide clinical decision making. Our findings should be interpreted cautiously due to the low response rate.
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Affiliation(s)
- André E. Bussières
- Assistant Professor, School of Physical and Occupational Therapy, McGill University
- Professor, Département Chiropratique, Université du Québec à Trois-Rivières
| | - Lauren Terhorst
- Associate Professor, Department of Occupational Therapy and Health and Community Systems, University of Pittsburgh
| | - Matthew Leach
- Senior Research Fellow, School of Nursing & Midwifery, University of South Australia
| | - Kent Stuber
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College
| | - Roni Evans
- Associate Professor, Center for Spirituality & Healing, Academic Health Center, University of Minnesota
| | - Michael J. Schneider
- Associate Professor, Department of Physical Therapy and Clinical and Translational Science Institute, University of Pittsburgh
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159
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Bhojani U, Kolsteren P, Criel B, De Henauw S, Beerenahally TS, Verstraeten R, Devadasan N. Intervening in the local health system to improve diabetes care: lessons from a health service experiment in a poor urban neighborhood in India. Glob Health Action 2015; 8:28762. [PMID: 26578110 PMCID: PMC4649018 DOI: 10.3402/gha.v8.28762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many efficacious health service interventions to improve diabetes care are known. However, there is little evidence on whether such interventions are effective while delivered in real-world resource-constrained settings. OBJECTIVE To evaluate an intervention aimed at improving diabetes care using the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework. DESIGN A quasi-experimental study was conducted in a poor urban neighborhood in South India. Four health facilities delivered the intervention (n=163 diabetes patients) and the four matched facilities served as control (n=154). The intervention included provision of culturally appropriate education to diabetes patients, use of generic medications, and standard treatment guidelines for diabetes management. Patients were surveyed before and after the 6-month intervention period. We did field observations and interviews with the doctors at the intervention facilities. Quantitative data were used to assess the reach of the intervention and its effectiveness on patients' knowledge, practice, healthcare expenditure, and glycemic control through a difference-in-differences analysis. Qualitative data were analyzed thematically to understand adoption, implementation, and maintenance of the intervention. RESULTS Reach: Of those who visited intervention facilities, 52.3% were exposed to the education component and only 7.2% were prescribed generic medications. The doctors rarely used the standard treatment guidelines for diabetes management. EFFECTIVENESS The intervention did not have a statistically and clinically significant impact on the knowledge, healthcare expenditure, or glycemic control of the patients, with marginal reduction in their practice score. Adoption: All the facilities adopted the education component, while all but one facility adopted the prescription of generic medications. IMPLEMENTATION There was poor implementation of the intervention, particularly with regard to the use of generic medications and the standard treatment guidelines. Doctors' concerns about the efficacy, quality, availability, and acceptability by patients of generic medications explained limited prescriptions of generic medications. The patients' perception that ailments should be treated through medications limited the use of non-medical management by the doctors in early stages of diabetes. The other reason for the limited use of the standard treatment guidelines was that these doctors mainly provided follow-up care to patients who were previously put on a given treatment plan by specialists. Maintenance: The intervention facilities continued using posters and television monitors for health education after the intervention period. The use of generic medications and standard treatment guidelines for diabetes management remained very limited. CONCLUSIONS Implementing efficacious health service intervention in a real-world resource-constrained setting is challenging and may not prove effective in improving patient outcomes. Interventions need to consider patients' and healthcare providers' experiences and perceptions and how macro-level policies translate into practice within local health systems.
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Affiliation(s)
- Upendra Bhojani
- Institute of Public Health, Bangalore, India.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Public Health, Ghent University, Ghent, Belgium;
| | - Patrick Kolsteren
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Roos Verstraeten
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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160
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Grudniewicz A, Bhattacharyya O, McKibbon KA, Straus SE. Redesigning printed educational materials for primary care physicians: design improvements increase usability. Implement Sci 2015; 10:156. [PMID: 26537589 PMCID: PMC4634785 DOI: 10.1186/s13012-015-0339-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 10/19/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Printed educational materials (PEMs) are a frequently used tool to disseminate clinical information and attempt to change behavior within primary care. However, their effect on clinician behavior is limited. In this study, we explored how PEMs can be redesigned to better meet the needs of primary care physicians (PCPs) and whether usability and selection can be increased when design principles and user preferences are used. METHODS We redesigned a publicly available PEM using physician preferences, design principles, and graphic designer support. We invited PCPs to select their preferred document between the redesigned and original versions in a discrete choice experiment, followed by an assessment of usability with the System Usability Scale and a think aloud process. We conducted this study in both a controlled and opportunistic setting to determine whether usability testing results vary by study location. Think aloud data was thematically analyzed, and results were interpreted using the Technology Acceptance Model. RESULTS One hundred and eighty four PCPs participated in the discrete choice experiment at the 2014 Family Medicine Forum, a large Canadian conference for family physicians. Of these, 87.7 % preferred the redesigned version. Follow-up interviews were held with a randomly selected group of seven participants. We repeated this in a controlled setting in Toronto, Canada, with a set of 14 participants. Using the System Usability Scale, we found that usability scores were significantly increased with the redesign (p < 0.001). We also found that when PCPs were given the choice between the two versions, they selected the redesigned version as their preferred PEM more often than the original (p < 0.001). Results did not appear to differ between the opportunistic and controlled setting. We used the results of the think aloud process to add to a list of end user preferences developed in a previous study. CONCLUSIONS We found that redesigning a PEM with user preferences and design principles can improve its usability and result in the PEM being selected more often than the original. We feel this finding supports the involvement of the user, application of design principles, and the assistance of a graphic designer in the development of PEMs.
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Affiliation(s)
- Agnes Grudniewicz
- Institute of Health Policy, Management & Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 7th Floor, East Building, Toronto, ON, Canada.
| | - Onil Bhattacharyya
- Women's College Hospital, University of Toronto, 77 Grenville St, Toronto, ON, M5S 1B3, Office 217, Canada.
| | - K Ann McKibbon
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, McMaster University Faculty of Health Sciences, Room 137 Communications Research Laboratory, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 7th Floor, East Building, Toronto, ON, Canada.
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Phillips CJ, Gordon DL. Pharmacist-led implementation of a vancomycin guideline across medical and surgical units: impact on clinical behavior and therapeutic drug monitoring outcomes. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2015; 4:145-152. [PMID: 29354529 PMCID: PMC5741020 DOI: 10.2147/iprp.s92850] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background Vancomycin is the antibiotic of choice for the treatment of serious infections such as methicillin-resistant Staphylococcus aureus (MRSA). Inappropriate prescribing of vancomycin can lead to therapeutic failure, antibiotic resistance, and drug toxicity. Objective To examine the effectiveness of pharmacist-led implementation of a clinical practice guideline for vancomycin dosing and monitoring in a teaching hospital. Methods An observational pre–post study design was undertaken to evaluate the implementation of the vancomycin guideline. The implementation strategy principally involved education, clinical vignettes, and provision of pocket guidelines to accompany release of the guideline to the hospital Intranet. The target cohort for clinical behavioral change was junior medical officers, as they perform the majority of prescribing and monitoring of vancomycin in hospitals. Assessment measures were recorded for vancomycin prescribing, therapeutic drug monitoring, and patient outcomes. Results Ninety-nine patients, 53 pre- and 46 post-implementation, were included in the study. Prescribing of a loading dose increased from 9% to 28% (P=0.02), and guideline adherence to starting maintenance dosing increased from 53% to 63% (P=0.32). Dose adjustment by doctors when blood concentrations were outside target increased from 53% to 71% (P=0.12), and correct timing of initial concentration measurement increased from 43% to 57% (P=0.23). Appropriately timed trough concentrations improved from 73% to 81% (P=0.08). Pre-dose (trough) concentrations in target range rose from 33% to 44% (P=0.10), while potentially toxic concentrations decreased from 32% to 21% (P=0.05) post-implementation. Infection cure rates for patients increased from 85% to 96% (P=0.11) after the guideline was implemented. Conclusion The implementation strategy employed in this study demonstrated potential effectiveness, and should prompt additional larger studies to optimize strategies that will translate into improved clinical practice using vancomycin.
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Affiliation(s)
- Cameron J Phillips
- Division of Pharmacy, SA Pharmacy, Flinders Medical Centre, Bedford Park.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide.,Department of Microbiology and Infectious Diseases, School of Medicine, Flinders University, Adelaide
| | - David L Gordon
- Department of Microbiology and Infectious Diseases, School of Medicine, Flinders University, Adelaide.,Department of Microbiology and Infectious Diseases, SA Pathology, Flinders Medical Centre, Bedford Park, SA, Australia
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162
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Johnson MJ, May CR. Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open 2015; 5:e008592. [PMID: 26423853 PMCID: PMC4593167 DOI: 10.1136/bmjopen-2015-008592] [Citation(s) in RCA: 262] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/27/2015] [Accepted: 09/04/2015] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Translating research evidence into routine clinical practice is notoriously difficult. Behavioural interventions are often used to change practice, although their success is variable and the characteristics of more successful interventions are unclear. We aimed to establish the characteristics of successful behaviour change interventions in healthcare. DESIGN We carried out a systematic overview of systematic reviews on the effectiveness of behaviour change interventions with a theory-led analysis using the constructs of normalisation process theory (NPT). MEDLINE, CINAHL, PsychINFO and the Cochrane Library were searched electronically from inception to July 2015. SETTING Primary and secondary care. PARTICIPANTS Participants were any patients and healthcare professionals in systematic reviews who met the inclusion criteria of having examined the effectiveness of professional interventions in improving professional practice and/or patient outcomes. INTERVENTIONS Professional interventions as defined by the Cochrane Effective Practice and Organisation of Care Review Group. PRIMARY AND SECONDARY OUTCOME MEASURES Success of each intervention in changing practice or patient outcomes, and their mechanisms of action. Reviews were coded as to the interventions included, how successful they had been and which NPT constructs its component interventions covered. RESULTS Searches identified 4724 articles, 67 of which met the inclusion criteria. Interventions fell into three main categories: persuasive; educational and informational; and action and monitoring. Interventions focusing on action or education (eg, Audit and Feedback, Reminders, Educational Outreach) acted on the NPT constructs of Collective Action and Reflexive Monitoring, and reviews using them tended to report more positive outcomes. CONCLUSIONS This theory-led analysis suggests that interventions which contribute to normative restructuring of practice, modifying peer group norms and expectations (eg, educational outreach) and relational restructuring, reinforcing modified peer group norms by emphasising the expectations of an external reference group (eg, Reminders, Audit and Feedback), offer the best chances of success. Combining such interventions is most likely to change behaviour.
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Affiliation(s)
- Mark J Johnson
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, and University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Carl R May
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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163
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van Riet Paap J, Vissers K, Iliffe S, Radbruch L, Hjermstad MJ, Chattat R, Vernooij-Dassen M, Engels Y. Strategies to implement evidence into practice to improve palliative care: recommendations of a nominal group approach with expert opinion leaders. BMC Palliat Care 2015; 14:47. [PMID: 26419434 PMCID: PMC4589187 DOI: 10.1186/s12904-015-0044-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 09/21/2015] [Indexed: 11/10/2022] Open
Abstract
Background In the past decades, many new insights and best practices in palliative care, a relatively new field in health care, have been published. However, this knowledge is often not implemented. The aim of this study therefore was to identify strategies to implement improvement activities identified in a research project within daily palliative care practice. Methods A nominal group technique was used with members of the IMPACT consortium, being international researchers and clinicians in cancer care, dementia care and palliative care. Participants identified and prioritized implementation strategies. Data was analyzed qualitatively using inductive coding. Results Twenty international clinicians and researchers participated in one of two parallel nominal group sessions. The recommended strategies to implement results from a research project were grouped in five common themes: 1. Dissemination of results e.g. by publishing results tailored to relevant audiences, 2. Identification and dissemination of unique selling points, 3. education e.g. by developing e-learning tools and integrating scientific evidence into core curricula, 4. Stimulation of participation of stakeholders, and 5. consideration of consequences e.g. rewarding services for their implementation successes but not services that fail to implement quality improvement activities. Discussion The added value of this nominal group study lies in the prioritisation by the experts of strategies to influence the implementation of quality improvement activities in palliative care. Efforts to ensure future use of scientific findings should be built into research projects in order to prevent waste of resources.
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Affiliation(s)
- Jasper van Riet Paap
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Lukas Radbruch
- Department of Palliative Medicine, Universitätsklinikum Bonn, Sigmund-Freud-Street 25, 53127, Bonn, Germany. .,Department of Palliative Care, Malteser Hospital Bonn/Rhein-Sieg, Bonn, Germany.
| | - Marianne J Hjermstad
- Regional Centre for Excellence in Palliative Care Department of Oncology, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424, Oslo, Norway. .,European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, P.O. Box 8905, N-7491, Trondheim, Norway.
| | - Rabih Chattat
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy.
| | - Myrra Vernooij-Dassen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Kalorama Foundation, Nijmegen, The Netherlands.
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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McCarter K, Britton B, Baker A, Halpin S, Beck A, Carter G, Wratten C, Bauer J, Booth D, Forbes E, Wolfenden L. Interventions to improve screening and appropriate referral of patients with cancer for distress: systematic review protocol. BMJ Open 2015; 5:e008277. [PMID: 26391631 PMCID: PMC4577928 DOI: 10.1136/bmjopen-2015-008277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION It is estimated that 35-40% of patients with cancer experience distress at some stage during their illness. Distress may affect functioning, capacity to cope, treatment compliance, quality of life and survival of patients with cancer. Best practice clinical guidelines recommend routine psychosocial distress screening and referral for further assessment and/or psychosocial support for patients with cancer. However, evidence suggests this care is not provided consistently. METHODS AND ANALYSIS We developed our methods following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The review is registered with PROSPERO and any amendments to the protocol will be tracked. The primary aim of this systematic review is to examine the impact of interventions delivered in healthcare settings that are aimed at (1) improving routine screening of patients for psychosocial distress and (2) referral of distressed patients with cancer for further assessment and/or psychosocial support. The effectiveness of such interventions in reducing psychosocial distress, and any unintended adverse effect of the intervention will also be assessed in patients with cancer. Data sources will include the bibliographic databases Cochrane Central Register of Controlled trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL. Eligible studies must compare an intervention (or two or more interventions) in a healthcare setting to improve the rate of screening for psychosocial distress and/or referral for further assessment and/or psychosocial support for patients with cancer with no intervention or 'usual' practice. Two investigators will independently review titles and abstracts, followed by full article reviews and data extraction. Disagreements will be resolved by consensus and if necessary, a third reviewer. Where studies are sufficiently homogenous, trial data will be pooled and meta-analyses performed. ETHICS AND DISSEMINATION No ethical issues are foreseen. The findings of this study will be disseminated widely via peer-reviewed publications and conference presentations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD4 2015017518.
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Affiliation(s)
- Kristen McCarter
- School of Psychology, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Ben Britton
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Amanda Baker
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Sean Halpin
- School of Psychology, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Alison Beck
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Gregory Carter
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Chris Wratten
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, New South Wales, Australia
| | - Judy Bauer
- Centre for Dietetics Research, The University of Queensland, St Lucia, Queensland, Australia
| | - Debbie Booth
- University Library, University of Newcastle, Callaghan, New South Wales, Australia
| | - Erin Forbes
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Luke Wolfenden
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
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van Riet Paap J, Vernooij-Dassen M, Sommerbakk R, Moyle W, Hjermstad MJ, Leppert W, Vissers K, Engels Y. Implementation of improvement strategies in palliative care: an integrative review. Implement Sci 2015. [PMID: 26210499 PMCID: PMC4515317 DOI: 10.1186/s13012-015-0293-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background The European population is ageing, and as a consequence, an increasing number of patients are in need of palliative care, including those with dementia. Although a growing number of new insights and best practices in palliative care have been published, they are often not implemented in daily practice. The aim of this integrative review is to provide an overview of implementation strategies that have been used to improve the organisation of palliative care. Methods Using an integrative literature review, we evaluated publications with strategies to improve the organisation of palliative care. Qualitative analysis of the included studies involved categorisation of the implementation strategies into subgroups, according to the type of implementation strategy. Results From the 2379 publications identified, 68 studies with an experimental or quasi-experimental design were included. These studies described improvements using educational strategies (n = 14), process mapping (n = 1), feedback (n = 1), multidisciplinary meetings (n = 1) and multi-faceted implementation strategies (n = 51). Fifty-three studies reported positive outcomes, 11 studies reported mixed effects and four studies showed a limited effect (two educational and two multi-faceted strategies). Conclusions This review is one of the first to provide an overview of the available literature in relation to strategies used to improve the organisation of palliative care. Since most studies reported positive results, further research is needed to identify and improve the effects of strategies aiming to improve the organisation of palliative care. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0293-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jasper van Riet Paap
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Myrra Vernooij-Dassen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Nijmegen Alzheimer Centre, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Kalorama Foundation, Nijmegen, The Netherlands.
| | - Ragni Sommerbakk
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, P.O. Box 8905, N-7491, Trondheim, Norway.
| | - Wendy Moyle
- Centre for Health Practice Innovation, Griffith Health Institute, Griffith University, 170 Kessels Road, Nathan, Brisbane, Australia.
| | - Marianne J Hjermstad
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, P.O. Box 8905, N-7491, Trondheim, Norway. .,Regional Centre for Excellence in Palliative Care Department of Oncology, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424, Oslo, Norway.
| | - Wojciech Leppert
- Department of Palliative Medicine, Poznan University of Medical Sciences, 61-245, Poznan, Poland.
| | - Kris Vissers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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166
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Yost J, Ganann R, Thompson D, Aloweni F, Newman K, Hazzan A, McKibbon A, Dobbins M, Ciliska D. The effectiveness of knowledge translation interventions for promoting evidence-informed decision-making among nurses in tertiary care: a systematic review and meta-analysis. Implement Sci 2015; 10:98. [PMID: 26169063 PMCID: PMC4499897 DOI: 10.1186/s13012-015-0286-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 06/30/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nurses are increasingly expected to engage in evidence-informed decision-making (EIDM) to improve client and system outcomes. Despite an improved awareness about EIDM, there is a lack of use of research evidence and understanding about the effectiveness of interventions to promote EIDM. This project aimed to discover if knowledge translation (KT) interventions directed to nurses in tertiary care are effective for improving EIDM knowledge, skills, behaviours, and, as a result, client outcomes. It also sought to understand contextual factors that affect the impact of such interventions. METHODS A systematic review funded by the Canadian Institutes of Health Research (PROSPERO registration: CRD42013003319) was conducted. Included studies examined the implementation of any KT intervention involving nurses in tertiary care to promote EIDM knowledge, skills, behaviours, and client outcomes or studies that examined contextual factors. Study designs included systematic reviews, quantitative, qualitative, and mixed method studies. The search included electronic databases and manual searching of published and unpublished literature to November 2012; key databases included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica (EMBASE). Two reviewers independently performed study selection, risk of bias assessment, and data extraction. Studies with quantitative data determined to be clinically homogeneous were synthesized using meta-analytic methods. Studies with quantitative data not appropriate for meta-analysis were synthesized narratively by outcome. Studies with qualitative data were synthesized by theme. RESULTS Of the 44,648 citations screened, 30 citations met the inclusion criteria (18 quantitative, 10 qualitative, and 2 mixed methods studies). The quality of studies with quantitative data ranged from very low to high, and quality criteria was generally met for studies with qualitative data. No studies evaluated the impact on knowledge and skills; they primarily investigated the effectiveness of multifaceted KT strategies for promoting EIDM behaviours and improving client outcomes. Almost all studies included an educational component. A meta-analysis of two studies determined that a multifaceted intervention (educational meetings and use of a mentor) did not increase engagement in a range of EIDM behaviours [mean difference 2.7, 95 % CI (-1.7 to 7.1), I (2) = 0 %]. Among the remaining studies, no definitive conclusions could be made about the relative effectiveness of the KT interventions due to variation of interventions and outcomes, as well as study limitations. Findings from studies with qualitative data identified the organizational, individual, and interpersonal factors, as well as characteristics of the innovation, that influence the success of implementation. CONCLUSIONS KT interventions are being implemented and evaluated on nurses' behaviour and client outcomes. This systematic review may inform the selection of KT interventions and outcomes among nurses in tertiary care and decisions about further research.
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Affiliation(s)
- Jennifer Yost
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - Rebecca Ganann
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - David Thompson
- School of Nursing, Faculty of Health and Behavioural Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON, Canada.
| | - Fazila Aloweni
- Singapore General Hospital, 31 Third Hospital Avenue, Singapore, Singapore.
| | - Kristine Newman
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, 350 Victoria Street, Toronto, ON, Canada.
| | - Afeez Hazzan
- Department of Medicine, McMaster University, St. Peter's Hospital-Hamilton Health Sciences, 88 Maplewood Avenue, Hamilton, ON, Canada.
| | - Ann McKibbon
- Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - Maureen Dobbins
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - Donna Ciliska
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
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167
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Zhu B, Li Z, Jiang L, Du B, Jiang Q, Wang M, Lou R, Xi X. Effect of a quality improvement program on weaning from mechanical ventilation: a cluster randomized trial. Intensive Care Med 2015; 41:1781-90. [PMID: 26156108 DOI: 10.1007/s00134-015-3958-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the efficacy of a quality improvement (QI) program for protocol-directed weaning from mechanical ventilation. METHODS This was a prospective, cluster randomized controlled trial. The study consisted of a baseline phase and a QI phase. Fourteen intensive care units (ICUs) in Beijing, China, were randomized into the QI group and non-QI group. The QI group received a QI program to improve the compliance with protocol-directed weaning during the QI phase. RESULTS A total of 444 patients were enrolled in the non-QI group (193 for the baseline, 251 for the QI phase) and 440 in the QI group (199 for the baseline, 241 for the QI phase). During the QI phase in the QI group, compared with the non-QI group, total duration of mechanical ventilation decreased from 7.0 to 3.0 days (p = 0.003), the time before the first weaning attempt decreased from 3.63 to 1.96 days (p = 0.003), length of ICU stay decreased from 10.0 to 6.0 days (p = 0.004), length of hospital stay decreased from 23.0 to 19.0 days (p < 0.001). These differences were also significant in the QI group when the QI phase was compared with the baseline phase. In addition, there was a significant reduction in the percentage of mechanical ventilation exceeding 21 days (p = 0.001) when the baseline phase was compared with the QI phase in the QI group. CONCLUSIONS The QI program involving protocol-directed weaning is associated with beneficial clinical outcomes in mechanically ventilated patients.
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Affiliation(s)
- Bo Zhu
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Zhiqiang Li
- Department of Critical Care Medicine, Hebei United University Affiliated Hospital, Tangshan, China.
| | - Li Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China.
| | - Qi Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Meiping Wang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Ran Lou
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Xiuming Xi
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
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Tavender EJ, Bosch M, Gruen RL, Green SE, Michie S, Brennan SE, Francis JJ, Ponsford JL, Knott JC, Meares S, Smyth T, O'Connor DA. Developing a targeted, theory-informed implementation intervention using two theoretical frameworks to address health professional and organisational factors: a case study to improve the management of mild traumatic brain injury in the emergency department. Implement Sci 2015; 10:74. [PMID: 26003785 PMCID: PMC4446082 DOI: 10.1186/s13012-015-0264-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury in the emergency department (ED), variations in practice exist. Interventions designed to implement recommended behaviours can reduce this variation. Using theory to inform intervention development is advocated; however, there is no consensus on how to select or apply theory. Integrative theoretical frameworks, based on syntheses of theories and theoretical constructs relevant to implementation, have the potential to assist in the intervention development process. This paper describes the process of applying two theoretical frameworks to investigate the factors influencing recommended behaviours and the choice of behaviour change techniques and modes of delivery for an implementation intervention. Methods A stepped approach was followed: (i) identification of locally applicable and actionable evidence-based recommendations as targets for change, (ii) selection and use of two theoretical frameworks for identifying barriers to and enablers of change (Theoretical Domains Framework and Model of Diffusion of Innovations in Service Organisations) and (iii) identification and operationalisation of intervention components (behaviour change techniques and modes of delivery) to address the barriers and enhance the enablers, informed by theory, evidence and feasibility/acceptability considerations. We illustrate this process in relation to one recommendation, prospective assessment of post-traumatic amnesia (PTA) by ED staff using a validated tool. Results Four recommendations for managing mild traumatic brain injury were targeted with the intervention. The intervention targeting the PTA recommendation consisted of 14 behaviour change techniques and addressed 6 theoretical domains and 5 organisational domains. The mode of delivery was informed by six Cochrane reviews. It was delivered via five intervention components : (i) local stakeholder meetings, (ii) identification of local opinion leader teams, (iii) a train-the-trainer workshop for appointed local opinion leaders, (iv) local training workshops for delivery by trained local opinion leaders and (v) provision of tools and materials to prompt recommended behaviours. Conclusions Two theoretical frameworks were used in a complementary manner to inform intervention development in managing mild traumatic brain injury in the ED. The effectiveness and cost-effectiveness of the developed intervention is being evaluated in a cluster randomised trial, part of the Neurotrauma Evidence Translation (NET) program.
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Affiliation(s)
- Emma J Tavender
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia. .,Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia.
| | - Marije Bosch
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia. .,Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia.
| | - Russell L Gruen
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia. .,Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia. .,Department of Trauma, The Alfred Hospital, Melbourne, Australia.
| | - Sally E Green
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London, UK.
| | - Sue E Brennan
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
| | - Jill J Francis
- School of Health Sciences, City University London, London, UK.
| | - Jennie L Ponsford
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia. .,Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, Australia. .,School of Psychological Sciences, Monash University, Melbourne, Australia.
| | - Jonathan C Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia. .,Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia.
| | - Sue Meares
- Department of Psychology, Macquarie University, Sydney, Australia.
| | - Tracy Smyth
- Emergency Department, Westmead Hospital, Westmead, Australia.
| | - Denise A O'Connor
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
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Gathara D, English M, van Hensbroek MB, Todd J, Allen E. Exploring sources of variability in adherence to guidelines across hospitals in low-income settings: a multi-level analysis of a cross-sectional survey of 22 hospitals. Implement Sci 2015; 10:60. [PMID: 25928803 PMCID: PMC4416316 DOI: 10.1186/s13012-015-0245-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 04/11/2015] [Indexed: 11/30/2022] Open
Abstract
Background Variability in processes of care and outcomes has been reported widely in high-income settings (at geographic, hospital, physician group and individual physician levels); however, such variability and the factors driving it are rarely examined in low-income settings. Methods Using data from a cross-sectional survey undertaken in 22 hospitals (60 case records from each hospital) across Kenya that aimed at evaluating the quality of routine hospital services, we sought to explore variability in four binary inpatient paediatric process indicators. These included three prescribing tasks and use of one diagnostic. To examine for sources of variability, we examined intra-class correlation coefficients (ICC) and their changes using multi-level mixed models with random intercepts for hospital and clinician levels and adjusting for patient and clinician level covariates. Results Levels of performance varied substantially across indicators and hospitals. The absolute values for ICCs also varied markedly ranging from a maximum of 0.48 to a minimum of 0.09 across the models for HIV testing and prescription of zinc, respectively. More variation was attributable at the hospital level than clinician level after allowing for nesting of clinicians within hospitals for prescription of quinine loading dose for malaria (ICC = 0.30), prescription of zinc for diarrhoea patients (ICC = 0.11) and HIV testing for all children (ICC = 0.43). However, for prescription of correct dose of crystalline penicillin, more of the variability was explained by the clinician level (ICC = 0.21). Adjusting for clinician and patient level covariates only altered, marginally, the ICCs observed in models for the zinc prescription indicator. Conclusions Performance varied greatly across place and indicator. The variability that could be explained suggests interventions to improve performance might be best targeted at hospital level factors for three indicators and clinician factors for one. Our data suggest that better understanding of performance and sources of variation might help tailor improvement interventions although further data across a larger set of indicators and sites would help substantiate these findings.
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Affiliation(s)
- David Gathara
- KEMRI Wellcome Trust Research Programme, 43640 - 00100, Nairobi, Kenya.
| | - Mike English
- KEMRI Wellcome Trust Research Programme, 43640 - 00100, Nairobi, Kenya. .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
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Joosen MCW, van Beurden KM, Terluin B, van Weeghel J, Brouwers EPM, van der Klink JJL. Improving occupational physicians' adherence to a practice guideline: feasibility and impact of a tailored implementation strategy. BMC MEDICAL EDUCATION 2015; 15:82. [PMID: 25903280 PMCID: PMC4469464 DOI: 10.1186/s12909-015-0364-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 04/14/2015] [Indexed: 05/24/2023]
Abstract
BACKGROUND Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs' barriers were evaluated. METHODS OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs' experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training. RESULTS The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01). CONCLUSIONS The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs' knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.
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Affiliation(s)
- Margot C W Joosen
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000, LE, Tilburg, The Netherlands.
| | - Karlijn M van Beurden
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000, LE, Tilburg, The Netherlands.
| | - Berend Terluin
- Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, EMGO Institute for Health and Care Research, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Jaap van Weeghel
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000, LE, Tilburg, The Netherlands.
- Phrenos Centre of Expertise, PO Box 1203, 3500, BE, Utrecht, The Netherlands.
- Parnassia Group, Dijk en Duin Mental Health Center, PO Box 305, 1900, AH, Castricum, The Netherlands.
| | - Evelien P M Brouwers
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000, LE, Tilburg, The Netherlands.
| | - Jac J L van der Klink
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000, LE, Tilburg, The Netherlands.
- Department of Health Sciences, Division of Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, A. Deusinglaan 1, 9713, AV, Groningen, The Netherlands.
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Abgrall S, Rachas A, Tourret J, Isnard-Bagnis C, Billaud E, Tattevin P, Costagliola D, Guiguet M, Durieux P. A multifaceted intervention designed to improve medical management of moderate to advanced chronic kidney disease in HIV-infected patients: a cluster randomized trial. Clin Infect Dis 2015; 61:375-84. [PMID: 25904366 DOI: 10.1093/cid/civ310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/04/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency virus (HIV). Progression to end-stage renal disease can be slowed by appropriate medical management. METHODS To assess whether active promotion of guidelines improves CKD management, we conducted a cluster randomized controlled trial within the French Hospital Database on HIV (FHDH-ANRS CO4). We randomized 46 centers participating in the FHDH to either simple information on guideline availability or active promotion with a multifaceted and repeated intervention comprising reminders and audit feedback and targeting of local opinion leaders carried out between April 2009 and April 2010. Outcome measure was CKD management adequacy assessed before and 2 years after the beginning of the intervention in HIV-infected patients with moderate to severe CKD. CKD management was considered adequate in case of referral to a nephrologist or if proteinuria, blood pressure, low-density lipoprotein cholesterol level, and glycemia had been measured during the previous year and medications had been prescribed when necessary. RESULTS Three hundred six patients were enrolled, of whom 238 (78%) completed the 2 years of follow-up. During the study period, the percentage of patients receiving adequate CKD management improved from 64.1% to 70.4% (+6.3%) in the active arm and from 68.3% to 75.6% (+7.3%) in the control arm (adjusted mean difference, -0.7 percentage points [95% confidence interval: -9.2 to 7.9]; P = .95). The biggest impact of active promotion was on the management of proteinuria and blood pressure. CONCLUSIONS Adequate compliance with CKD management guidelines improved slightly between 2009 and 2011, with no difference between the simple information and active promotion arms. CLINICAL TRIALS REGISTRATION CCTIRS 10.150 and CNIL DR-2010-379.
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Affiliation(s)
- Sophie Abgrall
- Sorbonne Universités, UPMC Université Paris 06 INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris AP-HP, Hôpital Antoine Béclère, Service de Médecine Interne, Clamart Paris-Sud 11 University, Le Kremlin-Bicêtre
| | - Antoine Rachas
- Paris Descartes University, Hôpital Européen Georges Pompidou INSERM UMRS 872 eq22
| | - Jérome Tourret
- Urology, Nephrology and Transplantation Department, Pitie-Salpetriere Hospital UPMC Paris Université 06
| | - Corinne Isnard-Bagnis
- Urology, Nephrology and Transplantation Department, Pitie-Salpetriere Hospital UPMC Paris Université 06 Chaire de recherche en éducation thérapeutique CNAM-EHESS, Paris
| | - Eric Billaud
- Hôtel-Dieu Universitary Hospital, Infectious Diseases Unit, Nantes
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Université Paris 06 INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris
| | - Marguerite Guiguet
- Sorbonne Universités, UPMC Université Paris 06 INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris
| | - Pierre Durieux
- Paris Descartes University, Hôpital Européen Georges Pompidou INSERM UMRS 872 eq22
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Gagliardi AR, Alhabib S. Trends in guideline implementation: a scoping systematic review. Implement Sci 2015; 10:54. [PMID: 25895908 PMCID: PMC4409784 DOI: 10.1186/s13012-015-0247-8] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/13/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers. METHODS A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies. RESULTS The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies. CONCLUSIONS While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.
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Affiliation(s)
- Anna R Gagliardi
- Toronto General Research Institute, University Health Network, Toronto, Canada.
| | - Samia Alhabib
- Department of Family & Community Medicine, King Abdullah University Hospital, Riyadh, Saudi Arabia.
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Yamada J, Shorkey A, Barwick M, Widger K, Stevens BJ. The effectiveness of toolkits as knowledge translation strategies for integrating evidence into clinical care: a systematic review. BMJ Open 2015; 5:e006808. [PMID: 25869686 PMCID: PMC4401869 DOI: 10.1136/bmjopen-2014-006808] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The aim of this systematic review was to evaluate the effectiveness of toolkits as a knowledge translation (KT) strategy for facilitating the implementation of evidence into clinical care. Toolkits include multiple resources for educating and/or facilitating behaviour change. DESIGN Systematic review of the literature on toolkits. METHODS A search was conducted on MEDLINE, EMBASE, PsycINFO and CINAHL. Studies were included if they evaluated the effectiveness of a toolkit to support the integration of evidence into clinical care, and if the KT goal(s) of the study were to inform, share knowledge, build awareness, change practice, change behaviour, and/or clinical outcomes in healthcare settings, inform policy, or to commercialise an innovation. Screening of studies, assessment of methodological quality and data extraction for the included studies were conducted by at least two reviewers. RESULTS 39 relevant studies were included for full review; 8 were rated as moderate to strong methodologically with clinical outcomes that could be somewhat attributed to the toolkit. Three of the eight studies evaluated the toolkit as a single KT intervention, while five embedded the toolkit into a multistrategy intervention. Six of the eight toolkits were partially or mostly effective in changing clinical outcomes and six studies reported on implementation outcomes. The types of resources embedded within toolkits varied but included predominantly educational materials. CONCLUSIONS Future toolkits should be informed by high-quality evidence and theory, and should be evaluated using rigorous study designs to explain the factors underlying their effectiveness and successful implementation.
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Affiliation(s)
- Janet Yamada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Melanie Barwick
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kimberley Widger
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bonnie J Stevens
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Giguere AM, Labrecque M, Légaré F, Grad R, Cauchon M, Greenway M, Haynes RB, Pluye P, Syed I, Banerjee D, Carmichael PH, Martin M. Feasibility of a randomized controlled trial to evaluate the impact of decision boxes on shared decision-making processes. BMC Med Inform Decis Mak 2015; 15:13. [PMID: 25880757 PMCID: PMC4350632 DOI: 10.1186/s12911-015-0134-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 01/27/2015] [Indexed: 12/04/2022] Open
Abstract
Background Decision boxes (DBoxes) are two-page evidence summaries to prepare clinicians for shared decision making (SDM). We sought to assess the feasibility of a clustered Randomized Controlled Trial (RCT) to evaluate their impact. Methods A convenience sample of clinicians (nurses, physicians and residents) from six primary healthcare clinics who received eight DBoxes and rated their interest in the topic and satisfaction. After consultations, their patients rated their involvement in decision-making processes (SDM-Q-9 instrument). We measured clinic and clinician recruitment rates, questionnaire completion rates, patient eligibility rates, and estimated the RCT needed sample size. Results Among the 20 family medicine clinics invited to participate in this study, four agreed to participate, giving an overall recruitment rate of 20%. Of 148 clinicians invited to the study, 93 participated (63%). Clinicians rated an interest in the topics ranging 6.4-8.2 out of 10 (with 10 highest) and a satisfaction with DBoxes of 4 or 5 out of 5 (with 5 highest) for 81% DBoxes. For the future RCT, we estimated that a sample size of 320 patients would allow detecting a 9% mean difference in the SDM-Q-9 ratings between our two arms (0.02 ICC; 0.05 significance level; 80% power). Conclusions Clinicians’ recruitment and questionnaire completion rates support the feasibility of the planned RCT. The level of interest of participants for the DBox topics, and their level of satisfaction with the Dboxes demonstrate the acceptability of the intervention. Processes to recruit clinics and patients should be optimized. Electronic supplementary material The online version of this article (doi:10.1186/s12911-015-0134-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anik Mc Giguere
- Research Centre for Excellence in Aging, CHU de Quebec, Saint-Sacrement Hospital, 1050 chemin Ste-Foy, Québec, Québec, G1S 4L8, Canada. .,Department of Family and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, 1050 avenue de la Medecine, Quebec City, Quebec, G1V 0A6, Canada.
| | - Michel Labrecque
- Department of Family and Emergency Medicine, Research Center of the CHU de Quebec, Saint-Francois d'Assise Hospital, Laval University, 10 rue de l'Espinay, D6-730, Quebec City, QC, G1L 3L5, Canada
| | - France Légaré
- Department of Family and Emergency Medicine, Research Center of the CHU de Quebec, Saint-Francois d'Assise Hospital, Laval University, 10 rue de l'Espinay, D6-730, Quebec City, QC, G1L 3L5, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Herzl Family Practice Centre, 3755 Cote Sainte Catherine, Montreal, QC H3T 1E2, Canada
| | - Michel Cauchon
- Department of Family and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, 1050 avenue de la Medecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Matthew Greenway
- Department of Family Medicine, McMaster University, 118 Lake Street, St. Catharines, ON, Canada
| | - R Brian Haynes
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, L8S 4K1, Canada.,Department of Medicine, DeGroote School of Medicine, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, L8S 4K1, Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, 5858 Côte-des-neiges, 3rd Floor, Suite 300, Montreal, QC, H3S 1Z1, Canada
| | - Iqra Syed
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, L8S 4K1, Canada
| | - Debi Banerjee
- The University of Toronto, Faculty of Medicine, 1 King's College Circle, Medical Sciences Building (Rm. 2109), Toronto, ON, M5S-1A8, Canada
| | - Pierre-Hugues Carmichael
- Research Centre for Excellence in Aging, CHU de Quebec, Saint-Sacrement Hospital, 1050 chemin Ste-Foy, Québec, Québec, G1S 4L8, Canada
| | - Mélanie Martin
- Research Centre for Excellence in Aging, CHU de Quebec, Saint-Sacrement Hospital, 1050 chemin Ste-Foy, Québec, Québec, G1S 4L8, Canada.,Department of Family and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, 1050 avenue de la Medecine, Quebec City, Quebec, G1V 0A6, Canada
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Hardy JR, Spruyt O, Quinn SJ, Devilee LR, Currow DC. Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine. Intern Med J 2015; 44:586-91. [PMID: 24720500 DOI: 10.1111/imj.12442] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 04/01/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND An adequately powered, double-blind, multisite, randomised controlled trial has shown no net clinical benefit for subcutaneous ketamine over placebo in the management of cancer pain refractory to combination opioid and co-analgesic therapy. The results of the trial were disseminated widely both nationally and internationally. AIM To determine whether the trial had impacted on clinical practice in Australasia. METHODS Members of the Australia and New Zealand Society of Palliative Medicine were sent an online ketamine utilisation survey. RESULTS A total of 123/392 clinicians responded (31% response rate). The majority of respondents had practised for more than 10 years in a metropolitan hospital setting. Ketamine had been prescribed by 91% of respondents, and 92% were aware of the trial. As a result, 65% of respondents had changed practice (17% no longer prescribed ketamine, 46% used less and 2% more). Thirty-five per cent had not changed practice. Reasons for change included belief in the results of the study, concerns over the toxicity reported or because there were alternatives for pain control. Of those who prescribed less, over 80% were more selective and would now only use the drug in certain clinical situations or pain types, or when all other medications had failed. CONCLUSIONS Although two-thirds of respondents reported practice change as a result of the randomised controlled trial, a minority remained convinced of the benefit of the drug from their own observations and would require additional evidence.
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Affiliation(s)
- J R Hardy
- Mater Health Services, Mater Research/University of Queensland, Brisbane, Queensland, Australia
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Gagliardi AR, Marshall C, Huckson S, James R, Moore V. Developing a checklist for guideline implementation planning: review and synthesis of guideline development and implementation advice. Implement Sci 2015; 10:19. [PMID: 25884601 PMCID: PMC4329197 DOI: 10.1186/s13012-015-0205-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/07/2015] [Indexed: 11/15/2022] Open
Abstract
Background Developers, users and others have requested or advocated for guidance on how to plan for, and implement guidelines concurrent to their development given that existing resources are lacking such information. The purpose of this research was to develop a guideline implementation planning checklist. Methods Documents that described or evaluated the processes of planning or undertaking implementation were identified in several publications that had systematically identified such resources, and by searching medical literature databases (MEDLINE, EMBASE). Data that described implementation planning; how to develop guideline versions or tools that would support user implementation; and options and mechanisms for disseminating or implementing guidelines were independently extracted from eligible documents by the principal investigator and a trained research assistant. Data were integrated to create a unique list of guideline implementation planning processes and considerations. Results Thirty-five documents were eligible. Of these, 16 (45.7%) provided sparse information on implementation planning, 25 (71.4%) mentioned different versions or tools for implementation, and 30 (85.7%) listed options for dissemination or implementation. None provided instructions for operationalizing implementation strategies. Data were integrated into a multi-item Guideline Implementation Planning Checklist including considerations for implementation planning (12), development of implementation tools (8), types of implementation tools (12), and options for dissemination (11) and implementation (12). Conclusions Developers or users can apply the Guideline Implementation Planning Checklist to prepare for and/or undertake guideline implementation. Further development of the checklist is warranted to elaborate on all components. In ongoing research, we will consult with the international guideline community to do so. At the same time, guideline implementation is complex, so developers and users would benefit from training, and by including knowledge translation experts and brokers on implementation planning committees. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0205-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Catherine Marshall
- Guideline Adviser and Health Sector Consultant, Waipukurau, New Zealand.
| | - Sue Huckson
- Australian and New Zealand Intensive Care Society, Melbourne, Australia.
| | - Roberta James
- Scottish Intercollegiate Guidelines Network, Edinburgh, Scotland.
| | - Val Moore
- National Institute for Health and Care Excellence, London, England.
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Törmä J, Winblad U, Saletti A, Cederholm T. Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents. J Nutr Health Aging 2015; 19:70-6. [PMID: 25560819 DOI: 10.1007/s12603-014-0522-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Studies on implementation techniques that focus on nutrition in the setting of elderly care are scarce. The aims of this study were to compare two implementation strategies i.e., external facilitation (EF) and educational outreach visits (EOVs), in order to introduce nutritional guidelines (e.g. screening, food quality and mealtime ambience), into a nursing home (NH) setting and to evaluate the clinical outcomes. DESIGN A controlled study with baseline and follow-up measurements. SETTING Four NHs. PARTICIPANTS A total of 101 NH residents. INTERVENTION The EF was a one-year, multifaceted intervention that included support, guidance, practice audits, and feedback that were provided to two NHs. The EOVs performed at the other NHs consisted of one session of three hours of lectures about the guidelines. Both interventions targeted a team of the unit manager, the head nurse, and 5-10 of the care staff. MEASUREMENTS The outcomes were nutritional status (Mini Nutritional Assessment-Short Form, MNA-SF), body mass index (BMI), functional ability (Barthel Index, BI), cognitive function (Short Portable Mental Status Questionnaire, SPMSQ, performed in a subgroup of communicative NH residents), health-related quality of life (EQ-5D), and the levels of certain biochemical markers like for example vitamin D, albumin and insulin-like growth factor 1. RESULTS After a median of 18 months, nutritional parameters (MNA-SF and BMI) remained unchanged in both groups. While there were no differences in most outcomes between the two groups, the cognitive ability of those in the EOV group deteriorated more than in individuals in the EF group (p=0.008). Multiple linear regression analyses indicated that the intervention group assignment (EF) was independently from other potentially related factors associated with less cognitive decline. CONCLUSION An extended model of implementation of nutritional guidelines, including guidance and feedback to NH staff, did not affect nutritional status but may be associated with a delayed cognitive decline in communicative NH residents.
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Affiliation(s)
- J Törmä
- Johanna Törmä, Uppsala University, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala Science Park, SE-751 85 Uppsala, Sweden; Phone: +46186117981; Fax: +46186117976; E-mail:
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Barac R, Stein S, Bruce B, Barwick M. Scoping review of toolkits as a knowledge translation strategy in health. BMC Med Inform Decis Mak 2014; 14:121. [PMID: 25539950 PMCID: PMC4308831 DOI: 10.1186/s12911-014-0121-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Significant resources are invested in the production of research knowledge with the ultimate objective of integrating research evidence into practice. Toolkits are becoming increasingly popular as a knowledge translation (KT) strategy for disseminating health information, to build awareness, inform, and change public and healthcare provider behavior. Toolkits communicate messages aimed at improving health and changing practice to diverse audiences, including healthcare practitioners, patients, community and health organizations, and policy makers. This scoping review explores the use of toolkits in health and healthcare. METHODS Using Arksey and O'Malley's scoping review framework, health-based toolkits were identified through a search of electronic databases and grey literature for relevant articles and toolkits published between 2004 and 2011. Two reviewers independently extracted data on toolkit topic, format, target audience, content, evidence underlying toolkit content, and evaluation of the toolkit as a KT strategy. RESULTS Among the 253 sources identified, 139 met initial inclusion criteria and 83 toolkits were included in the final sample. Fewer than half of the sources fully described the toolkit content and about 70% made some mention of the evidence underlying the content. Of 83 toolkits, only 31 (37%) had been evaluated at any level (27 toolkits were evaluated overall relative to their purpose or KT goal, and 4 toolkits evaluated the effectiveness of certain elements contained within them). CONCLUSIONS Toolkits used to disseminate health knowledge or support practice change often do not specify the evidence base from which they draw, and their effectiveness as a knowledge translation strategy is rarely assessed. To truly inform health and healthcare, toolkits should include comprehensive descriptions of their content, be explicit regarding content that is evidence-based, and include an evaluation of the their effectiveness as a KT strategy, addressing both clinical and implementation outcomes.
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Affiliation(s)
| | | | | | - Melanie Barwick
- Hospital for Sick Children, Toronto, Canada. .,University of Toronto, Toronto, Canada.
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Esposito P, Dal Canton A. Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology. World J Nephrol 2014; 3:249-255. [PMID: 25374819 PMCID: PMC4220358 DOI: 10.5527/wjn.v3.i4.249] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/01/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
Evaluation and improvement of quality of care provided to the patients are of crucial importance in the daily clinical practice and in the health policy planning and financing. Different tools have been developed, including incident analysis, health technology assessment and clinical audit. The clinical audit consist of measuring a clinical outcome or a process, against well-defined standards set on the principles of evidence-based medicine in order to identify the changes needed to improve the quality of care. In particular, patients suffering from chronic renal diseases, present many problems that have been set as topics for clinical audit projects, such as hypertension, anaemia and mineral metabolism management. Although the results of these studies have been encouraging, demonstrating the effectiveness of audit, overall the present evidence is not clearly in favour of clinical audit. These findings call attention to the need to further studies to validate this methodology in different operating scenarios. This review examines the principle of clinical audit, focusing on experiences performed in nephrology settings.
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Esslinger EE, Schade CP, Sun CK, Sun YH, Manna J, Hall BK, Wright S, Hannah KL, Lynch JR. Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients. J Eval Clin Pract 2014; 20:664-70. [PMID: 24935526 DOI: 10.1111/jep.12198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2014] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. METHOD We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively). RESULTS Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. CONCLUSION We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.
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Affiliation(s)
- E Eve Esslinger
- West Virginia Medical Institute and Quality Insights, Harrisburg, PA, USA
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Why children with severe bacterial infection die: a population-based study of determinants and consequences of suboptimal care with a special emphasis on methodological issues. PLoS One 2014; 9:e107286. [PMID: 25247401 PMCID: PMC4172434 DOI: 10.1371/journal.pone.0107286] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/12/2014] [Indexed: 12/31/2022] Open
Abstract
Introduction Suboptimal care is frequent in the management of severe bacterial infection. We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants. Methods A previously reported population-based confidential enquiry included all children (3 months- 16 years) who died of severe bacterial infection in a French area during a 7-year period. Here, we compared the optimality of the management of these cases to that of pediatric patients who survived a severe bacterial infection during the same period for 6 types of care: seeking medical care by parents, evaluation of sepsis signs and detection of severe disease by a physician, timing and dosage of antibiotic therapy, and timing and dosage of saline bolus. Two independent experts blinded to outcome and final diagnosis evaluated the optimality of these care types. The effect of suboptimal care on survival was analyzed by a logistic regression adjusted on confounding factors identified by a causal diagram. Determinants of suboptimal care were analyzed by multivariate multilevel logistic regression. Results Suboptimal care was significantly more frequent during early management of the 21 children who died as compared with the 93 survivors: 24% vs 13% (p = 0.003). The most frequent suboptimal care types were delay to seek medical care (20%), under-evaluation of severity by the physician (20%) and delayed antibiotic therapy (24%). Young age (under 1 year) was independently associated with higher risk of suboptimal care, whereas being under the care of a paediatric emergency specialist or a mobile medical unit as compared with a general practitioner was associated with reduced risk. Conclusions Suboptimal care in the early management of severe bacterial infection had a global independent negative effect on survival. Suboptimal care may be avoided by better training of primary care physicians in the specifics of pediatric medicine.
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Légaré F, Stacey D, Turcotte S, Cossi MJ, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner-Banzhoff N. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2014:CD006732. [PMID: 25222632 DOI: 10.1002/14651858.cd006732.pub3] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Shared decision making (SDM) can reduce overuse of options not associated with benefits for all and respects patient rights, but has not yet been widely adopted in practice. OBJECTIVES To determine the effectiveness of interventions to improve healthcare professionals' adoption of SDM. SEARCH METHODS For this update we searched for primary studies in The Cochrane Library, MEDLINE, EMBASE, CINAHL, the Cochrane Effective Practice and Organisation of Care (EPOC) Specialsied Register and PsycINFO for the period March 2009 to August 2012. We searched the Clinical Trials.gov registry and the proceedings of the International Shared Decision Making Conference. We scanned the bibliographies of relevant papers and studies. We contacted experts in the field to identify papers published after August 2012. SELECTION CRITERIA Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies evaluating interventions to improve healthcare professionals' adoption of SDM where the primary outcomes were evaluated using observer-based outcome measures (OBOM) or patient-reported outcome measures (PROM). DATA COLLECTION AND ANALYSIS The three overall categories of intervention were: interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Studies in each category were compared to studies in the same category, to studies in the other two categories, and to usual care, resulting in nine comparison groups. Statistical analysis considered categorical and continuous primary outcomes separately. We calculated the median of the standardized mean difference (SMD), or risk difference, and range of effect across studies and categories of intervention. We assessed risk of bias. MAIN RESULTS Thirty-nine studies were included, 38 randomised and one non-randomised controlled trial. Categorical measures did not show any effect for any of the interventions. In OBOM studies, interventions targeting both patients and healthcare professionals had a positive effect compared to usual care (SMD of 2.83) and compared to interventions targeting patients alone (SMD of 1.42). Studies comparing interventions targeting patients with other interventions targeting patients had a positive effect, as did studies comparing interventions targeting healthcare professionals with usual care (SDM of 1.13 and 1.08 respectively). In PROM studies, only three comparisons showed any effect, patient compared to usual care (SMD of 0.21), patient compared to another patient (SDM of 0.29) and healthcare professional compared to another healthcare professional (SDM of 0.20). For all comparisons, interpretation of the results needs to consider the small number of studies, the heterogeneity, and some methodological issues. Overall quality of the evidence for the outcomes, assessed with the GRADE tool, ranged from low to very low. AUTHORS' CONCLUSIONS It is uncertain whether interventions to improve adoption of SDM are effective given the low quality of the evidence. However, any intervention that actively targets patients, healthcare professionals, or both, is better than none. Also, interventions targeting patients and healthcare professionals together show more promise than those targeting only one or the other.
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Affiliation(s)
- France Légaré
- Population Health and Optimal Health Practices Research Axis, CHU de Québec Research Center, Université Laval, 10 Rue de l'Espinay, D6-727, Québec City, Québec, Canada, G1L 3L5
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Lassi ZS, Das JK, Salam RA, Bhutta ZA. Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings. Reprod Health 2014; 11 Suppl 2:S2. [PMID: 25209692 PMCID: PMC4160921 DOI: 10.1186/1742-4755-11-s2-s2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews. Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize.
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Affiliation(s)
- Zohra S Lassi
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Jai K Das
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Rehana A Salam
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Program for Global Pediatric Research, Hospital For Sick Children, Toronto
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Kawchuk G, Newton G, Srbely J, Passmore S, Bussières A, Busse JW, Bruno P. Knowledge Transfer within the Canadian Chiropractic Community. Part 2: Narrowing the Evidence-Practice Gap. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2014; 58:206-14. [PMID: 25202148 PMCID: PMC4139759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Greg Kawchuk
- Professor and Canada Research Chair in Spinal Function, Faculty of Rehabilitation Medicine, University of Alberta
| | - Genevieve Newton
- Assistant Professor, Department of Human Health and Nutritional Sciences, University of Guelph
| | - John Srbely
- Assistant Professor and CCRF Chair in Spine Mechanics and Neurophysiology, Human Health and Nutritional Science, University of Guelph
| | - Steven Passmore
- Assistant Professor, CCRF Professorship, School of Medical Rehabilitation, Faculty of Medicine, University of Manitoba
- Assistant Professor (Adjunct), Research Department, New York Chiropractic College
| | - André Bussières
- Assistant Professor and CCRF Research Chair in Rehabilitation Epidemiology, School of Physical and Occupational Therapy, McGill University
- Professor, Université du Québec à Trois-Rivières
| | - Jason W. Busse
- Assistant Professor, Department of Anesthesia, McMaster University, Hamilton, Canada
- Assistant Professor, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Researcher, the Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Paul Bruno
- Assistant Professor and CCRF Research Chair in Neuromusculoskeletal Health, Faculty of Kinesiology and Health Studies, University of Regina
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Connell LA, McMahon NE, Harris JE, Watkins CL, Eng JJ. A formative evaluation of the implementation of an upper limb stroke rehabilitation intervention in clinical practice: a qualitative interview study. Implement Sci 2014; 9:90. [PMID: 25112430 PMCID: PMC4156624 DOI: 10.1186/s13012-014-0090-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 06/27/2014] [Indexed: 02/01/2023] Open
Abstract
Background The Graded Repetitive Arm Supplementary Program (GRASP) is a hand and arm exercise programme designed to increase the intensity of exercise achieved in inpatient stroke rehabilitation. GRASP was shown to be effective in a randomised controlled trial in 2009 and has since experienced unusually rapid uptake into clinical practice. The aim of this study was to conduct a formative evaluation of the implementation of GRASP to inform the development and implementation of a similar intervention in the United Kingdom. Methods Semi-structured interviews were conducted with therapists who were involved in implementing GRASP at their work site, or who had experience of using GRASP. Normalisation Process Theory (NPT), a sociological theory used to explore the processes of embedding innovations in practice, was used to develop an interview guide. Intervention components outlined within the GRASP Guideline Manual were used to develop prompts to explore how therapists use GRASP in practice. Interview transcripts were analysed using a coding frame based on implementation theory. Results Twenty interviews were conducted across eight sites in British Columbia Canada. Therapists identified informal networks and the free online availability of GRASP as key factors in finding out about the intervention. All therapists reported positive opinions about the value of GRASP. At all sites, therapists identified individuals who advocated for the use of GRASP, and in six of the eight sites this was the practice leader or senior therapist. Rehabilitation assistants were identified as instrumental in delivering GRASP in almost all sites as they were responsible for organising the GRASP equipment and assisting patients using GRASP. Almost all intervention components were found to be adapted to some degree when used in clinical practice; coverage was wider, the content adapted, and the dose, when monitored, was less. Conclusions Although GRASP has translated into clinical practice, it is not always used in the way in which it was shown to be effective. This formative evaluation has informed the development of a novel intervention which aims to bridge this evidence-practice gap in upper limb rehabilitation after stroke. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0090-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise A Connell
- Clinical Practice Research Unit, School of Health, University of Central Lancashire, Preston PR1 2HE, UK.
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186
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Blanc X, Collet TH, Auer R, Fischer R, Locatelli I, Iriarte P, Krause J, Légaré F, Cornuz J. Publication trends of shared decision making in 15 high impact medical journals: a full-text review with bibliometric analysis. BMC Med Inform Decis Mak 2014; 14:71. [PMID: 25106844 PMCID: PMC4136407 DOI: 10.1186/1472-6947-14-71] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/04/2014] [Indexed: 11/24/2022] Open
Abstract
Background Shared Decision Making (SDM) is increasingly advocated as a model for medical decision making. However, there is still low use of SDM in clinical practice. High impact factor journals might represent an efficient way for its dissemination. We aimed to identify and characterize publication trends of SDM in 15 high impact medical journals. Methods We selected the 15 general and internal medicine journals with the highest impact factor publishing original articles, letters and editorials. We retrieved publications from 1996 to 2011 through the full-text search function on each journal website and abstracted bibliometric data. We included publications of any type containing the phrase “shared decision making” or five other variants in their abstract or full text. These were referred to as SDM publications. A polynomial Poisson regression model with logarithmic link function was used to assess the evolution across the period of the number of SDM publications according to publication characteristics. Results We identified 1285 SDM publications out of 229,179 publications in 15 journals from 1996 to 2011. The absolute number of SDM publications by journal ranged from 2 to 273 over 16 years. SDM publications increased both in absolute and relative numbers per year, from 46 (0.32% relative to all publications from the 15 journals) in 1996 to 165 (1.17%) in 2011. This growth was exponential (P < 0.01). We found fewer research publications (465, 36.2% of all SDM publications) than non-research publications, which included non-systematic reviews, letters, and editorials. The increase of research publications across time was linear. Full-text search retrieved ten times more SDM publications than a similar PubMed search (1285 vs. 119 respectively). Conclusion This review in full-text showed that SDM publications increased exponentially in major medical journals from 1996 to 2011. This growth might reflect an increased dissemination of the SDM concept to the medical community.
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Affiliation(s)
- Xavier Blanc
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland.
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187
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Zwarenstein M, Shiller SK, Croxford R, Grimshaw JM, Kelsall D, Paterson JM, Laupacis A, Austin PC, Tu K, Yun L, Hux JE. Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial [ISRCTN72772651]. Implement Sci 2014; 9:87. [PMID: 25098587 PMCID: PMC4261896 DOI: 10.1186/1748-5908-9-87] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 05/05/2014] [Indexed: 11/10/2022] Open
Abstract
Background Evidence of the effectiveness of printed educational messages in narrowing the gap between guideline recommendations and practice is contradictory. Failure to screen for retinopathy exposes primary care patients with diabetes to risk of eye complications. Screening is initiated by referral from family practitioners but adherence to guidelines is suboptimal. We aimed to evaluate the ability of printed educational messages aimed at family doctors to increase retinal screening of primary care patients with diabetes. Methods Design: Pragmatic 2×3 factorial cluster trial randomized by physician practice, involving 5,048 general practitioners (with 179,833 patients with diabetes). Setting: Ontario family practitioners. Interventions: Reminders (that retinal screening helps prevent diabetes-related vision loss and is covered by provincial health insurance for patients with diabetes) with prompts to encourage screening were mailed to each physician in conjunction with a widely-read professional newsletter. Alternative printed materials formats were an ‘outsert’ (short, directive message stapled to the outside of the newsletter), and/or a two-page, evidence-based article (‘insert’) and a pre-printed sticky note reminder for patients. Main outcome measure: A successful outcome was an eye examination (which includes retinal screening) provided to a patient with diabetes, not screened in the previous 12 months, within 90 days after visiting a family practitioner. Analysis accounted for clustering of doctors within practice groups. Results No intervention effect was detected (eye exam rates were 31.6% for patients of control physicians, 31.3% for the insert, 32.8% for the outsert, 32.3% for those who received both, and 31.2% for those who received both plus the patient reminder with the largest 95% confidence interval around any effect extending from −1.3% to 1.1%). Conclusions This large trial conclusively failed to demonstrate any impact of printed educational messages on screening uptake. Despite their low cost, printed educational messages should not be routinely used in attempting to close evidence-practice gaps relating to diabetic retinopathy screening. Trial registration ISRCTN72772651 Electronic supplementary material The online version of this article (doi:10.1186/1748-5908-9-87) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, London, Ontario N6A 3K7, Canada.
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188
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Grimshaw JM, Presseau J, Tetroe J, Eccles MP, Francis JJ, Godin G, Graham ID, Hux JE, Johnston M, Légaré F, Lemyre L, Robinson N, Zwarenstein M. Looking inside the black box: results of a theory-based process evaluation exploring the results of a randomized controlled trial of printed educational messages to increase primary care physicians' diabetic retinopathy referrals [Trial registration number ISRCTN72772651]. Implement Sci 2014; 9:86. [PMID: 25098442 PMCID: PMC4261878 DOI: 10.1186/1748-5908-9-86] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 04/21/2014] [Indexed: 11/16/2022] Open
Abstract
Background Theory-based process evaluations conducted alongside randomized controlled trials provide the opportunity to investigate hypothesized mechanisms of action of interventions, helping to build a cumulative knowledge base and to inform the interpretation of individual trial outcomes. Our objective was to identify the underlying causal mechanisms in a cluster randomized trial of the effectiveness of printed educational materials (PEMs) to increase referral for diabetic retinopathy screening. We hypothesized that the PEMs would increase physicians’ intention to refer patients for retinal screening by strengthening their attitude and subjective norm, but not their perceived behavioral control. Methods Design: A theory based process evaluation alongside the Ontario Printed Educational Material (OPEM) cluster randomized trial. Postal surveys based on the Theory of Planned Behavior were sent to a random sample of trial participants two months before and six months after they received the intervention. Setting: Family physicians in Ontario, Canada. Participants: 1,512 family physicians (252 per intervention group) from the OPEM trial were invited to participate, and 31.3% (473/1512) responded at time one and time two. The final sample comprised 437 family physicians fully completing questionnaires at both time points. Main outcome measures: Primary: behavioral intention related to referring patient for retinopathy screening; secondary: attitude, subjective norm, perceived behavioral control. Results At baseline, family physicians reported positive intention, attitude, subjective norm, and perceived behavioral control to advise patients about retinopathy screening suggesting limited opportunities for improvement in these constructs. There were no significant differences on intention, attitude, subjective norm, and perceived behavioral control following the intervention. Respondents also reported additional physician- and patient-related factors perceived to influence whether patients received retinopathy screening. Conclusions Lack of change in the primary and secondary theory-based outcomes provides an explanation for the lack of observed effect of the main OPEM trial. High baseline levels of intention to advise patients to attend retinopathy screening suggest that post-intentional and other factors may explain gaps in care. Process evaluations based on behavioral theory can provide replicable and generalizable insights to aid interpretation of randomized controlled trials of complex interventions to change health professional behavior. Trial registration ISRCTN72772651. Electronic supplementary material The online version of this article (doi:10.1186/1748-5908-9-86) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeremy M Grimshaw
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8 L6, Canada.
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Bush SH, Bruera E, Lawlor PG, Kanji S, Davis DHJ, Agar M, Wright DK, Hartwick M, Currow DC, Gagnon B, Simon J, Pereira JL. Clinical practice guidelines for delirium management: potential application in palliative care. J Pain Symptom Manage 2014; 48:249-58. [PMID: 24766743 PMCID: PMC4128754 DOI: 10.1016/j.jpainsymman.2013.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 09/05/2013] [Accepted: 09/10/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear. OBJECTIVES This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development. METHODS We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting. RESULTS There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care. CONCLUSION Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
| | - Eduardo Bruera
- The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Peter G Lawlor
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniel H J Davis
- Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Meera Agar
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | | | - Michael Hartwick
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada
| | - David C Currow
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Bruno Gagnon
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec City, Québec, Canada; Centre de recherche du CHU de Québec, Québec City, Québec, Canada
| | - Jessica Simon
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - José L Pereira
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
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Hirschhorn AD, Kolt GS, Brooks AJ. A multicomponent theory-based intervention improves uptake of pelvic floor muscle training before radical prostatectomy: a 'before and after' cohort study. BJU Int 2014; 113:383-92. [PMID: 24053154 PMCID: PMC4155862 DOI: 10.1111/bju.12385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of a multicomponent theory-based intervention, incorporating patient information guides, an evidence summary, audit and feedback processes and a provider directory, in the provision/receipt of preoperative pelvic floor muscle training (PFMT) among patients undergoing radical prostatectomy. SUBJECTS AND METHODS Over an 18-month period (9 months before and 9 months after the intervention), we measured the provision/receipt of preoperative PFMT using surveys of patients undergoing radical prostatectomy at one public hospital (n = 32) and two private hospitals (n = 107) in Western Sydney, Australia, as well as practice audits of associated public sector (n = 4) and private sector (n = 2) providers of PFMT. Self-report urinary incontinence was assessed 3 months after radical prostatectomy using the International Consultation on Incontinence Questionnaire - Urinary Incontinence Form (ICIQ-UI Short Form). RESULTS There was a significant increase in the proportion of survey respondents receiving preoperative PFMT post-intervention (post-intervention: 42/58 respondents, 72% vs pre-intervention: 37/81 respondents, 46%, P = 0.002). There was a corresponding significant increase in provision of preoperative PFMT by private sector providers (mean [sd] post-intervention: 16.7 [3.7] patients/month vs pre-intervention: 12.1 [3.6] patients/month, P = 0.018). Respondents receiving preoperative PFMT had significantly better self-report urinary incontinence at 3 months after radical prostatectomy than those who did not receive preoperative PFMT (mean [sd] ICIQ-UI Short Form sum-scores: 6.2 [5.0] vs 9.2 [5.8], P = 0.002). CONCLUSIONS The intervention increased the provision/receipt of preoperative PFMT among patients undergoing radical prostatectomy. Additional component strategies aimed at increasing the use of public sector providers may be necessary to further improve PFMT receipt among patients undergoing radical prostatectomy in the public hospital system.
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Affiliation(s)
- Andrew D Hirschhorn
- School of Science and Health, University of Western Sydney, Penrith; Westmead Private Physiotherapy Services, NSW, Australia
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Daniels K, Odendaal WA, Nkonki L, Hongoro C, Colvin CJ, Lewin S. Incentives for lay health workers to improve recruitment, retention in service and performance. Hippokratia 2014. [DOI: 10.1002/14651858.cd011201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Karen Daniels
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
| | - Willem A Odendaal
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
| | - Lungiswa Nkonki
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
- Stellenbosch University; Centre for Health Systems and Services Research and Development; Cape Town South Africa
| | - Charles Hongoro
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
- Human Sciences Research Council; Health Systems Financing, Population Health, Health Systems and Innovation Programme; Cape Town South Africa
| | - Christopher J Colvin
- School of Public Health and Family Medicine, University of Cape Town; Centre for Infectious Disease Epidemiology and Research (CIDER); 7 Alfred St., Observatory 7925 Cape Town South Africa
| | - Simon Lewin
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
- Norwegian Knowledge Centre for the Health Services; Global Health Unit; Box 7004 St Olavsplass Oslo Norway N-0130
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192
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Nadeem E, Gleacher A, Beidas RS. Consultation as an implementation strategy for evidence-based practices across multiple contexts: unpacking the black box. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2014; 40:439-50. [PMID: 23716145 DOI: 10.1007/s10488-013-0502-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
There is great interest in the dissemination and implementation of evidence-based treatments and practices for children across schools and community mental health settings. A growing body of literature suggests that the use of one-time workshops as a training tool is ineffective in influencing therapist behavior and patient outcomes and that ongoing expert consultation and coaching is critical to actual uptake and quality implementation. Yet, we have very limited understanding of how expert consultation fits into the larger implementation support system, or the most effective consultation strategies. This commentary reviews the literature on consultation in child mental health, and proposes a set of core consultation functions, processes, and outcomes that should be further studied in the implementation of evidence-based practices for children.
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Affiliation(s)
- Erum Nadeem
- Department of Child and Adolescent Psychiatry, New York University, One Park Avenue, 7th Floor, New York, NY, 10016, USA,
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193
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Ohl CA, Luther VP. Health Care Provider Education as a Tool to Enhance Antibiotic Stewardship Practices. Infect Dis Clin North Am 2014; 28:177-93. [DOI: 10.1016/j.idc.2014.02.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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194
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Brown B(B, Young J, Smith DP, Kneebone AB, Brooks AJ, Xhilaga M, Dominello A, O’Connell DL, Haines M. Clinician-led improvement in cancer care (CLICC)--testing a multifaceted implementation strategy to increase evidence-based prostate cancer care: phased randomised controlled trial--study protocol. Implement Sci 2014; 9:64. [PMID: 24884877 PMCID: PMC4048539 DOI: 10.1186/1748-5908-9-64] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 05/22/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Clinical practice guidelines have been widely developed and disseminated with the aim of improving healthcare processes and patient outcomes but the uptake of evidence-based practice remains haphazard. There is a need to develop effective implementation methods to achieve large-scale adoption of proven innovations and recommended care. Clinical networks are increasingly being viewed as a vehicle through which evidence-based care can be embedded into healthcare systems using a collegial approach to agree on and implement a range of strategies within hospitals. In Australia, the provision of evidence-based care for men with prostate cancer has been identified as a high priority. Clinical audits have shown that fewer than 10% of patients in New South Wales (NSW) Australia at high risk of recurrence after radical prostatectomy receive guideline recommended radiation treatment following surgery. This trial will test a clinical network-based intervention to improve uptake of guideline recommended care for men with high-risk prostate cancer. METHODS/DESIGN In Phase I, a phased randomised cluster trial will test a multifaceted intervention that harnesses the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network to increase evidence-based care for men with high-risk prostate cancer following surgery. The intervention will be introduced in nine NSW hospitals over 10 months using a stepped wedge design. Outcome data (referral to radiation oncology for discussion of adjuvant radiotherapy in line with guideline recommended care or referral to a clinical trial of adjuvant versus salvage radiotherapy) will be collected through review of patient medical records. In Phase II, mixed methods will be used to identify mechanisms of provider and organisational change. Clinicians' knowledge and attitudes will be assessed through surveys. Process outcome measures will be assessed through document review. Semi-structured interviews will be conducted to elucidate mechanisms of change. DISCUSSION The study will be one of the first randomised controlled trials to test the effectiveness of clinical networks to lead changes in clinical practice in hospitals treating patients with high-risk cancer. It will additionally provide direction regarding implementation strategies that can be effectively employed to encourage widespread adoption of clinical practice guidelines. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910.
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Affiliation(s)
- Bernadette (Bea) Brown
- Sax Institute, Haymarket, Australia
- School of Public Health, University of Sydney, Camperdown, Australia
| | - Jane Young
- School of Public Health, University of Sydney, Camperdown, Australia
| | - David P Smith
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
- Griffith Health Institute, Griffith University, Gold Coast, QLD, Australia
| | - Andrew B Kneebone
- Department of Radiation Oncology, Royal North Shore Hospital, Sydney, Australia
- Northern Clinical School, University of Sydney, Camperdown, Australia
| | - Andrew J Brooks
- NSW Agency for Clinical Innovation, Sydney, Australia
- Westmead Private Hospital, Westmead, Australia
- Westmead Clinical School, University of Sydney, Camperdown, Australia
| | - Miranda Xhilaga
- Prostate Cancer Foundation of Australia, Melbourne, Australia
| | | | - Dianne L O’Connell
- School of Public Health, University of Sydney, Camperdown, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Mary Haines
- Sax Institute, Haymarket, Australia
- School of Public Health, University of Sydney, Camperdown, Australia
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195
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Abstract
OBJECTIVE To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation. BACKGROUND The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain. METHODS Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science. RESULTS A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results. CONCLUSIONS Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.
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196
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Muramoto ML, Hall JR, Nichter M, Nichter M, Aickin M, Connolly T, Matthews E, Campbell JZ, Lando HA. Activating lay health influencers to promote tobacco cessation. Am J Health Behav 2014; 38:392-403. [PMID: 24636035 DOI: 10.5993/ajhb.38.3.8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate the effect of tobacco cessation brief-intervention (BI) training for lay "health influencers," on knowledge, self-efficacy and the proportion of participants reporting BI delivery post-training. METHODS Randomized, community-based study comparing In-person or Web-based training, with mailed materials. RESULTS In-person and Web-training groups had significant post-training cessation knowledge and self-efficacy gains. All groups increased the proportion of individuals reporting BIs at follow-up, with no significant between-group differences. Irrespective of participants' prior intervention experience, 80%-86% reported BIs within the past 90 days; 71%-79% reported >1 in the past 30. CONCLUSIONS Web and In-person training significantly increase health influencer cessation knowledge and self-efficacy. With minimal prompting and materials, even persons without BI experience can be activated to encourage tobacco cessation.
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Affiliation(s)
- Myra L Muramoto
- University of Arizona Department of Family and Community Medicine, Tucson, AZ, USA.
| | - John R Hall
- University of Arizona Health Sciences Center, Tucson, AZ, USA
| | - Mark Nichter
- University of Arizona Department of Anthropology, Tucson, AZ, USA
| | - Mimi Nichter
- University of Arizona Department of Anthropology, Tucson, AZ, USA
| | - Mikel Aickin
- University of Arizona Department of Family and Community Medicine, Tucson, AZ, USA
| | - Tim Connolly
- University of Arizona Department of Family and Community Medicine, Tucson, AZ, USA
| | - Eva Matthews
- University of Arizona Department of Family and Community Medicine, Tucson, AZ, USA
| | - Jean Z Campbell
- University of Arizona Department of Family and Community Medicine, Tucson, AZ, USA
| | - Harry A Lando
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
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197
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Hollon SD, Areán PA, Craske MG, Crawford KA, Kivlahan DR, Magnavita JJ, Ollendick TH, Sexton TL, Spring B, Bufka LF, Galper DI, Kurtzman H. Development of Clinical Practice Guidelines. Annu Rev Clin Psychol 2014; 10:213-41. [DOI: 10.1146/annurev-clinpsy-050212-185529] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, high-quality guidelines can facilitate shared decision making and identify gaps in knowledge.
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Affiliation(s)
- Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee 37240
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Patricia A. Areán
- Department of Psychiatry, School of Medicine, University of California, San Francisco, California 94143
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Michelle G. Craske
- Department of Psychology, University of California, Los Angeles, California 90095
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Kermit A. Crawford
- Center for Multicultural Mental Health, Boston University Medical Campus, Boston, Massachusetts 02118
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Daniel R. Kivlahan
- Department of Psychiatry and Behavioral Sciences, University of Washington and Mental Health Services, Veterans Health Administration, Seattle, Washington 98108
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Jeffrey J. Magnavita
- Glastonbury Psychological Associates, Glastonbury, Connecticut 06033
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Thomas H. Ollendick
- Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Thomas L. Sexton
- Department of Counseling and Educational Psychology, Indiana University, Bloomington, Indiana 47405
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Bonnie Spring
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois 60611
- Advisory Steering Committee, American Psychological Association, Washington, DC 20002
| | - Lynn F. Bufka
- American Psychological Association, Washington, DC 20002
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198
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Bryant J, Boyes A, Jones K, Sanson-Fisher R, Carey M, Fry R. Examining and addressing evidence-practice gaps in cancer care: a systematic review. Implement Sci 2014; 9:37. [PMID: 24666544 PMCID: PMC4114221 DOI: 10.1186/1748-5908-9-37] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 03/21/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There is increasing recognition of gaps between best scientific evidence and clinical practice. This systematic review aimed to assess the volume and scope of peer-reviewed cancer research output in the years 2000, 2005, and 2010. METHODS Eligible papers were published in English and reported on evidence-practice gaps in cancer care. The electronic database Medline was searched for three time periods using MeSH headings and keywords. Abstracts were assessed against eligibility criteria by one reviewer and checked by a second. Papers meeting eligibility criteria were coded as data-based or non-data-based, and by cancer type of focus. All data-based papers were then further classified as descriptive studies documenting the extent of, or barriers to addressing, the evidence-practice gap; or intervention studies examining the effectiveness of strategies to reduce the evidence-practice gap. RESULTS A total of 176 eligible papers were identified. The number of publications significantly increased over time, from 25 in 2000 to 100 in 2010 (p < 0.001). Of the 176 identified papers, 160 were data-based. The majority of these (n = 150) reported descriptive studies. Only 10 studies examined the effectiveness of interventions designed to reduce discrepancies between evidence and clinical practice. Of these, only one was a randomized controlled trial. Of all data-based studies, almost one-third (n = 48) examined breast cancer care. CONCLUSIONS While the number of publications investigating evidence-practice gaps in cancer care increased over a ten-year period, most studies continued to describe gaps between best evidence and clinical practice, rather than rigorously testing interventions to reduce the gap.
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Affiliation(s)
- Jamie Bryant
- Priority Research Center for Health Behavior, Health Behavior Research Group, University of Newcastle and Hunter Medical Research Institute. HMRI Building, University of Newcastle, Callaghan NSW, Australia
| | - Allison Boyes
- Priority Research Center for Health Behavior, Health Behavior Research Group, University of Newcastle and Hunter Medical Research Institute. HMRI Building, University of Newcastle, Callaghan NSW, Australia
| | - Kimberley Jones
- Priority Research Center for Health Behavior, Health Behavior Research Group, University of Newcastle and Hunter Medical Research Institute. HMRI Building, University of Newcastle, Callaghan NSW, Australia
| | - Rob Sanson-Fisher
- Priority Research Center for Health Behavior, Health Behavior Research Group, University of Newcastle and Hunter Medical Research Institute. HMRI Building, University of Newcastle, Callaghan NSW, Australia
| | - Mariko Carey
- Priority Research Center for Health Behavior, Health Behavior Research Group, University of Newcastle and Hunter Medical Research Institute. HMRI Building, University of Newcastle, Callaghan NSW, Australia
| | - Rae Fry
- Cancer Council New South Wales, Woolloomooloo NSW, Australia
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Childbirth care practices in public sector facilities in Jeddah, Saudi Arabia: a descriptive study. Midwifery 2014; 30:899-909. [PMID: 24703810 DOI: 10.1016/j.midw.2014.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 02/01/2014] [Accepted: 03/06/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES to explore reported hospital policies and practices during normal childbirth in maternity wards in Jeddah, Saudi Arabia, to assess and verify whether these practices are evidence-based. DESIGN quantitative design, in the form of a descriptive questionnaire, based on a tool extracted from the literature. SETTING nine government hospitals in Jeddah, Saudi Arabia. These hospitals have varied ownership, including Ministry of Health (MOH), military, teaching and other government hospitals. PARTICIPANTS key individuals responsible for the day-to-day running of the maternity ward. MEASUREMENTS nine interviews using descriptive structured questionnaire were conducted. Data were analysed using SPSS for Windows (version 16.0). FINDINGS the surveyed hospitals were found to be well equipped to deal with obstetric emergencies, and many follow evidence-based procedures. On average, the caesarean section rate was found to be 22.4%, but with considerable variances between hospitals. Some unnecessary procedures that are known to be ineffective or harmful and that are not recommended for routine use, including pubic shaving, enemas, episiotomy, electronic fetal monitoring (EFM) and intravenous (IV) infusion, were found to be frequently practiced. Only 22% of the hospitals sampled reported allowing a companion to attend labour and childbirth. KEY CONCLUSIONS many aspects of recommended EBP were used in the hospitals studied. However, the results of this study clearly indicate that there is wide variation between hospitals in Jeddah, Saudi Arabia in some obstetric practices. Furthermore, the findings suggest that some practices at these hospitals are not supported by evidence as being beneficial for mothers or infants and are positively discouraged under international guidelines. IMPLICATIONS FOR PRACTICE this study has specific implications for obstetricians, midwives and nurses working in maternity units. It gives an overview of current hospital policies and practices during normal childbirth. It is likely to contribute to improving the health and well-being of women, and have implications for service provision. It could also help in the development of technical information for policy-makers, and health care professionals for normal childbirth care.
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Challenges to implementation of an epidermal growth factor receptor testing strategy for non-small-cell lung cancer in a publicly funded health care system. J Thorac Oncol 2014; 8:1136-41. [PMID: 23887170 DOI: 10.1097/jto.0b013e31829f6a43] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data from seven recent randomized clinical trials have demonstrated that epidermal growth factor (EGFR) mutation status is predictive of improved progression-free survival and quality of life from first-line EGFR tyrosine kinase inhibitor therapy compared with platinum-based chemotherapy. We examined barriers to the initial implementation of a national EGFR testing policy in Canada. METHODS Five laboratories across Canada underwent a validation and quality-control exercise for EGFR mutation testing using reverse transcriptase-polymerase chain reaction with financial support from the pharmaceutical industry for the initial 12 months. Oncologists registered patients with nonquamous histology for EGFR mutation testing using a Web-based platform. Basic demographics were collected including age, histology, sex, smoking status, and ethnicity. The decision to prescribe gefitinib was subsequently registered on the system. RESULTS Between March and December 2010, 2104 requests were received for EGFR mutation testing. Demographic details are as follows: adenocarcinoma (91.6%); Asian ethnicity (13.9%); female (58%); light/never smoker (41.3%); stage IV disease (87.1%). The number of tests requested each month ranged from 200 to 250. Mutation testing was conducted in 1771 of 2104 requests (84%). The median turnaround time for EGFR testing was 18 days (standard deviation 9.7). Gefitinib was prescribed in 302 patients (17.1%). The number of test requests dropped to 50 to 100 per month at the end of the initial 12 months. CONCLUSION There was rapid uptake of EGFR mutation testing into routine clinical practice in Canada. Uptake of EGFR mutation testing dropped substantially once funding from pharmaceutical industry was discontinued. There is a need for a national strategy to ensure resources are in place to implement molecular testing for new molecularly targeted agents.
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