Audit and feedback: effects on professional practice and health care outcomes

An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices?

Background

Prescribing is a core activity for general practitioners, yet significant variation in the quality of prescribing has been reported. This suggests there may be room for improvement in the application of the current best research evidence. There has been substantial investment in technologies and interventions to address this issue, but effect sizes so far have been small to moderate. This suggests that prescribing is a decision-making process that is not sufficiently understood. By understanding more about prescribing processes and the implementation of research evidence, variation may more easily be understood and more effective interventions proposed.

Methods

An ethnographic study in three Scottish general practices with diverse organizational characteristics. Practices were ranked by their performance against Audit Scotland prescribing quality indicators, incorporating established best research evidence. Two practices of high prescribing quality and one practice of low prescribing quality were recruited. Participant observation, formal and informal interviews, and a review of practice documentation were employed.

Results

Practices ranked as high prescribing quality consistently made and applied macro and micro prescribing decisions, whereas the low-ranking practice only made micro prescribing decisions. Macro prescribing decisions were collective, policy decisions made considering research evidence in light of the average patient, one disease, condition, or drug. Micro prescribing decisions were made in consultation with the patient considering their views, preferences, circumstances and other conditions (if necessary).

Although micro prescribing can operate independently, the implementation of evidence-based, quality prescribing was attributable to an interdependent relationship. Macro prescribing policy enabled prescribing decisions to be based on scientific evidence and applied consistently where possible. Ultimately, this influenced prescribing decisions that occur at the micro level in consultation with patients.

Conclusion

General practitioners in the higher prescribing quality practices made two different ‘types’ of prescribing decision; macro and micro. Macro prescribing informs micro prescribing and without a macro basis to draw upon the low-ranked practice had no effective mechanism to engage with, reflect on and implement relevant evidence. Practices that recognize these two levels of decision making about prescribing are more likely to be able to implement higher quality evidence.

Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt

OBJECTIVE

To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both.

METHODS

Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22, 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010.

RESULTS

Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the family-focused intervention for HPV #1, but less effective for HPV #2 and 3.

CONCLUSIONS

A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.

Too complicated for the field? Measuring quality of care in humanitarian aid settings

While quality of care is a major concern in the western world, not many studies investigate this topic in low-income countries. Even less is known about the quality of care in humanitarian aid settings, where additional challenges from natural or manmade disasters contribute to additional challenges. This study tried to address this gap by introducing a new approach to systematically measure quality of care in a project of Médecins Sans Frontières (MSF) in Agok area, between South Sudan and Sudan. Our objective was to obtain a valid snapshot of quality of care for a MSF project in three weeks that has the potential to serve as a baseline for quality improvement strategies. The evaluation followed a cross-sectional study design to assess structural, process and outcome quality according to Donabedian's criteria of quality of care. A bundle of well-established methods for collection of quantitative and qualitative data was used to assess the project by following a triangulated mixed-methods approach. Mean structural quality scored 73% of expected performance level and mean process quality 59%. The overall mortality rate for the hospital was 3.6%. On average, less complicated cases got a better level of care than patients who were seriously ill. Significant motivational issues were discovered in staff interviews potentially affecting quality of care. The tool appeared to be quick, feasible and effective in judging quality of care in the selected project. To tap the whole potential of the approach a re-evaluation should be carried out to assess the effectiveness of implemented improvement strategies in Agok. To confirm the usefulness of the approach, more studies are needed covering the variety of different humanitarian aid settings.

The delivery of preventive care to clients of community health services

Background

Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients.

Methods

In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care.

Results

Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%).

Conclusions

Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

Ten-year results of quality assurance in radiotherapy chart round

Background

The Royal Australian and New Zealand College of Radiologists (RANZCR) initiated a unique instrument to audit the quality of patient notes and radiotherapy prescriptions. We present our experience collected over ten years from the use of the RANZCR audit instrument.

Methods

In this study, the results of data collected prospectively from January 1999 to June 2009 through the audit instrument were assessed. Radiotherapy chart rounds were held weekly in the uro-oncology tumour stream and real time feedback was provided. Electronic medical records were retrospectively assessed in September 2009 to see if any omissions were subsequently corrected.

Results

In total 2597 patients were audited. One hundred and thirty seven (5%) patients had one hundred and ninety nine omissions in documentation or radiotherapy prescription. In 79% of chart rounds no omissions were found at all, in 12% of chart rounds one omission was found and in 9% of chart rounds two or more omissions were found. Out of 199 omissions, 95% were of record keeping and 2% were omissions in the treatment prescription. Of omissions, 152 (76%) were unfiled investigation results of which 77 (51%) were subsequently corrected.

Conclusions

Real-time audit with feedback is an effective tool in assessing the standards of radiotherapy documentation in our department, and also probably contributed to the high level of attentiveness. A large proportion of omissions were investigation results, which highlights the need for an improved system of retrieval of investigation results in the radiation oncology department.

Feedback as a strategy to change behaviour: the devil is in the details

BACKGROUND

Performance feedback is one of a number of strategies used to improve clinical practice among students and clinicians.

OBJECTIVES

The aims of this paper were to examine conceptual underpinnings and essential components for audit and feedback strategies, to assess the extent to which recently published audit and feedback interventions include these components and to recommend future directions for feedback to improve its educational and behavioural impact.

METHODS

Based on the actionable feedback model, we examined the presence of four theoretical constructs--timeliness, individualization, lack of punitiveness and customizability--in studies published during 2009-2010 which included a feedback intervention.

RESULTS

There was wide variation in the definition, implementation and outcomes of 'feedback' interventions, making it difficult to compare across studies. None of the studies we reviewed included all of the components of the actionable feedback model.

CONCLUSIONS

Feedback interventions reported to date, even when results are positive, often fail to include concepts of behaviour change. This may partially explain the large variation in approaches and in results of such interventions and presents major challenges for replicating any given intervention. If feedback processes are to be successfully used and disseminated and implemented widely, some standardization and certainly more clarity is needed in the specific action steps taken to apply behavioural theory to practice.

Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59-4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05-1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

Methods for improving the quality of palliative care delivery: a systematic review

BACKGROUND

The effectiveness for improving the outcomes across palliative care domains remains unclear. We conducted a systematic review of different types of quality improvement interventions relevant to palliative care.

METHODS

We searched PubMed, CINAHL, PsycINFO, and Cochrane for relevant articles published between 2000 and 2011.

RESULTS

A total of 10 randomized controlled trials and 7 nonrandomized controlled trials were included. Of the 5 studies using relay of clinical information, 1 reported significant improvement in patient quality of life. Of the 5 studies targeting education and self-management, 4 found significant improvements in quality of life or patient symptoms.

CONCLUSION

A minority of quality improvement interventions have succeeded in improving the quality of palliative care delivery. More studies are needed on specific quality improvement types, including organizational change and multiple types of interventions.

Enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: Executive summary

This report is part of a series of white papers commissioned for the American Society for Radiation Oncology (ASTRO) Board of Directors as part of ASTRO's Target Safely Campaign, focusing on the role of peer review as an important component of a broad safety/quality assurance (QA) program. Peer review is one of the most effective means for assuring the quality of qualitative, and potentially controversial, patient-specific decisions in radiation oncology. This report summarizes many of the areas throughout radiation therapy that may benefit from the application of peer review. Each radiation oncology facility should evaluate the issues raised and develop improved ways to apply the concept of peer review to its individual process and workflow. This might consist of a daily multidisciplinary (eg, physicians, dosimetrists, physicists, therapists) meeting to review patients being considered for, or undergoing planning for, radiation therapy (eg, intention to treat and target delineation), as well as meetings to review patients already under treatment (eg, adequacy of image guidance). This report is intended to clarify and broaden the understanding of radiation oncology professionals regarding the meaning, roles, benefits, and targets for peer review as a routine quality assurance tool. It is hoped that this work will be a catalyst for further investigation, development, and study of the efficacy of peer review techniques and how these efforts can help improve the safety and quality of our treatments.

Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol)

BACKGROUND

Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care.

METHODS/DESIGN

This study is a pragmatic cluster randomized controlled trial, conducted in primary care (OPTI-SCRIPT trial), involving 22 practices (clusters) and 220 patients. Practices will be allocated to intervention or control arms using minimization, with intervention participants receiving a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing. Routinely collected national prescribing data will also be analyzed for nonparticipating practices, acting as a contemporary national control. The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient. In addition, economic and qualitative evaluations will be conducted.

DISCUSSION

This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges.

TRIAL REGISTRATION

Current controlled trials ISRCTN41694007.

Evaluation of the end user (dentist) experience of undertaking clinical audit in the post April 2001 general dental services (GDS) scheme

INTRODUCTION

A mandatory scheme for clinical audit in the general dental services (GDS) was launched in April 2001. No evaluation of this mandatory scheme exists in the literature. This study provides an evaluation of this scheme. More recently a new dental contract was introduced in the general dental services (GDS) in April 2006. Responsibility for clinical audit activities was devolved to primary care trusts (PCTs) as part of their clinical governance remit.

METHODS

All GDPs within Essex were contacted by letter and invited to participate in the research. A qualitative research method was selected for this evaluation, utilising audio-taped semi-structured research interviews with eight general dental practitioners (GDPs) who had taken part in the GDS clinical audit scheme and who fitted the sampling criteria and strategy. The evaluation focused on dentists' experiences of the scheme.

RESULTS

The main findings from the analysis of the GDS scheme data suggest that there is clear evidence of change following audit activities occurring within practices and for the benefit of patients. However, often it is the dentist only that undertakes a clinical audit project rather than the dental team, there is a lack of dissemination of project findings beyond the individual participating practices, very little useful feedback provided to participants who have completed a project and very limited use of formal re-auditing of a particular topic.

CONCLUSIONS

This study provides evaluation of the GDS clinical audit scheme. Organisations who propose to undertake clinical audit activities in conjunction with dentistry in the future may benefit from incorporating and/or developing some findings from this evaluation into their project design and avoiding others.

Clinician adherence to a standardized assessment battery across settings and disciplines in a poststroke rehabilitation population

OBJECTIVES

(1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence.

DESIGN

Retrospective cohort study.

SETTING

Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists).

PARTICIPANTS

Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence ≥5% and if so, how long the increase lasted.

RESULTS

Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P≤.001), with PT having the highest adherence across all 3 disciplines (P<.004). Of the 25 events conducted across the 17-month period to improve adherence, 10 (40%) resulted in a ≥5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month.

CONCLUSIONS

Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time.

Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention

BACKGROUND

Audit with feedback is a moderately effective approach for improving professional practice in other health care settings. Although unregulated caregivers give the majority of direct care in long-term care settings, little is known about how they understand and perceive feedback reports because unregulated providers have not been directly targeted to receive audit with feedback in quality improvement interventions in long-term care. The purpose of this paper is to describe unregulated care providers' perceptions of usefulness of a feedback report in four Canadian long-term care facilities.

METHODS

We delivered monthly feedback reports to unregulated care providers for 13 months in 2009-2010. The feedback reports described a unit's performance in relation to falls, depression, and pain as compared to eight other units in the study. Follow-up surveys captured participant perceptions of the feedback report. We conducted descriptive analyses of the variables related to participant perceptions and multivariable logistic regression to assess the association between perceived usefulness of the feedback report and a set of independent variables.

RESULTS

The vast majority (80%) of unregulated care providers (n = 171) who responded said they understood the reports. Those who discussed the report with others and were interested in other forms of data were more likely to find the feedback report useful for making changes in resident care.

CONCLUSIONS

This work suggests that unregulated care providers can understand and feel positively about using audit with feedback reports to make changes to resident care. Further research should explore ways to promote fuller engagement of unregulated care providers in decision-making to improve quality of care in long-term care settings.

Improving psychotherapeutic medication prescribing in Florida: implementation of the Florida Medicaid Drug Therapy Management Program (MDTMP)

This paper describes a program that was established by Florida Medicaid to improve the quality of prescribing of psychotherapeutic medications. It relates the process used for defining quality medication treatment including the definitions of unusual psychotherapeutic medication indicators (UPMI). It details the results of analysis of FY 2007-2008 pharmacy claims data using these indicators that enabled the Program to identify practices and prescribers that required targeted interventions. The most frequently triggered UPMI for adults involved the use of 2 or more antipsychotics for greater than 60 days; high doses of psychotherapeutic medications was the indicator most frequently triggered for children closely followed by the use of 2 or more antipsychotics for more than 45 days. Prescriptions that triggered UPMI were concentrated in a small number of prescribers. These results led to the Program focusing on these high frequency practices and on the prescribers most associated with them. They also led to the implementation of new quality improvement initiatives like the implementation of a psychiatric telephone consultation line for pediatricians who are treating children with serious emotional disturbances who do not have access to child psychiatrists.

Improving referral of patients for consideration of adjuvant chemotherapy after surgical resection of lung cancer

BACKGROUND

Clinical trials demonstrate improved survival for patients with completely resected non-small-cell lung cancer (nsclc) who receive adjuvant chemotherapy. Concerns have been raised about the implementation of those data. The present study measured rates of referral for adjuvant chemotherapy and barriers to referral, and it also evaluated a knowledge translation strategy to change practice.

METHODS

An audit and feedback approach was used. Using a retrospective cohort of patients undergoing thoracotomy at St. Joseph's Hospital in Hamilton, Ontario, during January-December 2008, anonymized data were presented to a group of thoracic surgeons for evaluation and feedback.

RESULTS

Among 150 thoracotomies performed, 55 patients with nsclc were potentially eligible for adjuvant chemotherapy, but only 27 (49%) were referred for it. Significant variability in referral between surgeons (19%-100%) was observed. Reasons for non-referral were poorly documented in the medical record, but appeared to be primarily the surgeon's decision. The feedback session with surgeons produced a number of constructive suggestions to implement change in practice.

CONCLUSIONS

Our findings suggest that surgeon choice was the most significant barrier to implementation of adjuvant chemotherapy for nsclc. Audit and feedback was a useful knowledge translation strategy. However, longer follow-up is needed to document change in practice.

Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial

BACKGROUND

Over 20% of hospital bed use is inappropriate, implying a waste of resources and the increase of patient iatrogenic risk.

METHODS

This is a cluster, pragmatic, randomised controlled trial, carried out in a large University Hospital of Northern Italy, aiming to evaluate the effect of a strategy to reduce unnecessary hospital days. The primary outcome was the percentage of patient-days compatible with discharge. Among secondary objectives, to describe the strategy's effect in the long-term, as well as on hospital readmissions, considered to be a marker of the quality of hospital care. The 12 medical wards with the longest length of stay participated. Effectiveness was measured at the individual level on 3498 eligible patients during monthly index days. Patients admitted or discharged on index days, or with stay >90 days, were excluded. All ward staff was blinded to the index days, while staff in the control arm and data analysts were blinded to the trial's objectives and interventions. The strategy comprised the distribution to physicians of the list of their patients whose hospital stay was compatible with discharge according to a validated Delay Tool, and of physician length of stay profiles, followed by audits managed autonomously by the physicians of the ward.

RESULTS

During the 12 months of data collection, over 50% of patient-days were judged to be compatible with discharge. Delays were mainly due to problems with activities under medical staff control. Multivariate analysis considering clustering showed that the strategy reduced patient-days compatible with discharge by 16% in the intervention vs control group, (OR=0.841; 95% CI, 0.735 to 0.963; P=0.012). Follow-up at 1 year did not yield a statistically significant difference between the percentages of patient-days judged to be compatible with discharge between the two arms (OR=0.818; 95% CI, 0.476 to 1.405; P=0.47). There was no significant difference in 30-day readmission and mortality rates for all eligible patients (N=3498) between the two arms.

CONCLUSIONS

Results indicate that a strategy, involving physician direct accountability, can reduce unnecessary hospital days. Relatively simple interventions, like the one assessed in this study, should be implemented in all hospitals with excessive lengths of stay, since unnecessary prolongation may be harmful to patients.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01422811.

Capacity-building and clinical competence in infectious disease in Uganda: a mixed-design study with pre/post and cluster-randomized trial components

Trial Design

Best practices for training mid-level practitioners (MLPs) to improve global health-services are not well-characterized. Two hypotheses were: 1) Integrated Management of Infectious Disease (IMID) training would improve clinical competence as tested with a single arm, pre-post design, and 2) on-site support (OSS) would yield additional improvements as tested with a cluster-randomized trial.

Methods

Thirty-six Ugandan health facilities (randomized 1∶1 to parallel OSS and control arms) enrolled two MLPs each. All MLPs participated in IMID (3-week core course, two 1-week boost sessions, distance learning). After the 3-week course, OSS-arm trainees participated in monthly OSS. Twelve written case scenarios tested clinical competencies in HIV/AIDS, tuberculosis, malaria, and other infectious diseases. Each participant completed different randomly-assigned blocks of four scenarios before IMID (t0), after 3-week course (t1), and after second boost course (t2, 24 weeks after t1). Scoring guides were harmonized with IMID content and Ugandan national policy. Score analyses used a linear mixed-effects model. The primary outcome measure was longitudinal change in scenario scores.

Results

Scores were available for 856 scenarios. Mean correct scores at t0, t1, and t2 were 39.3%, 49.1%, and 49.6%, respectively. Mean score increases (95% CI, p-value) for t0–t1 (pre-post period) and t1–t2 (parallel-arm period) were 12.1 ((9.6, 14.6), p<0.001) and −0.6 ((−3.1, +1.9), p = 0.647) percent for OSS arm and 7.5 ((5.0, 10.0), p<0.001) and 1.6 ((−1.0, +4.1), p = 0.225) for control arm. The estimated mean difference in t1 to t2 score change, comparing arm A (participated in OSS) vs. arm B was −2.2 ((−5.8, +1.4), p = 0.237). From t0–t2, mean scores increased for all 12 scenarios.

Conclusions

Clinical competence increased significantly after a 3-week core course; improvement persisted for 24 weeks. No additional impact of OSS was observed. Data on clinical practice, facility-level performance and health outcomes will complete assessment of overall impact of IMID and OSS.

Trial Registration

ClinicalTrials.gov NCT01190540

Knowledge translation in Uganda: a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework

Background

A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this ‘know-do’ gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the sub-elements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting.

Methods

This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data.

Results

The sub-elements of organizational context in the PARIHS framework—i.e., receptive context, culture, leadership, and evaluation—also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT.

Conclusions

In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings—resources, community involvement, and commitment and informal payment—should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate sub-element of the PARIHS framework as a whole.

Effecting change in primary care management of respiratory conditions: a global scoping exercise and literature review of educational interventions to inform the IPCRG's E-Quality initiative

This discussion paper describes a scoping exercise and literature review commissioned by the International Primary Care Respiratory Group (IPCRG) to inform their E-Quality programme which seeks to support small-scale educational projects to improve respiratory management in primary care. Our narrative review synthesises information from three sources: publications concerning the global context and health systems development; a literature search of Medline, CINAHL and Cochrane databases; and a series of eight interviews conducted with members of the IPCRG faculty. Educational interventions sit within complex healthcare, economic, and policy contexts. It is essential that any development project considers the local circumstances in terms of economic resources, political circumstances, organisation and administrative capacities, as well as the specific quality issue to be addressed. There is limited evidence (in terms of changed clinician behaviour and/or improved health outcomes) regarding the merits of different educational and quality improvement approaches. Features of educational interventions that were most likely to show some evidence of effectiveness included being carefully designed, multifaceted, engaged health professionals in their learning, provided ongoing support, were sensitive to local circumstances, and delivered in combination with other quality improvement strategies. To be effective, educational interventions must consider the complex healthcare systems within which they operate. The criteria for the IPCRG E-Quality awards thus require applicants not only to describe their proposed educational initiative but also to consider the practical and local barriers to successful implementation, and to propose a robust evaluation in terms of changed clinician behaviour or improved health outcomes.

Leading on the frontlines with passion and persistence: a necessary condition for Breastfeeding Best Practice Guideline uptake

AIMS AND OBJECTIVES

The research question explored was what are the processes and strategies used by frontline leaders to support the uptake of the Breastfeeding Best Practice Guideline by nurses in maternity care practice settings?

BACKGROUND

Best Practice Guidelines have been shown to enhance client care and outcomes. Leadership is known to have a key role in moving Best Practice Guidelines into nursing practice yet how this happens is poorly understood. This insight is needed to consistently and efficiently facilitate Best Practice Guideline uptake into clinical practice.

DESIGN

Constructivist grounded theory was used to explore the social processes and strategies involved in facilitating Best Practice Guideline uptake.

METHODS

Purposive, criterion-based, theoretical and negative case sampling were used recruiting 58 health professionals and 54 clients. Triangulation and constant comparison of data sources and types (interviews, documents and field notes) were used for analysis and rigour.

RESULTS

Passionate, persistent, respected frontline leaders using tailored, multifaceted strategies aimed at three groups of nurse adopters effectively support the uptake of the Breastfeeding Best Practice Guideline in nursing practice. Successful uptake strategies used by frontline leaders that are new or underdeveloped in the previous literature are presented.

CONCLUSIONS

The study findings illuminated multidimensional, tailored strategies that frontline leaders use to facilitate the uptake of Best Practice Guidelines. Attention to individual attitudes and beliefs, as well as organisational, interorganisational and interprofessional partnerships are vital to uptake. Organisations that aspire to foster Best Practice Guideline uptake must invest in frontline leaders to 'make it happen' and sustain Best Practice Guideline uptake in practice.

RELEVANCE TO CLINICAL PRACTICE

Understanding how frontline leaders facilitate Best Practice Guideline uptake is essential to selecting, educating and supporting them to foster desired practice changes. Strategies are explicated that frontline leaders can adopt and tailor to their own practice contexts.

Peri-operative nurses' knowledge and reported practice of pressure injury risk assessment and prevention: A before-after intervention study

BACKGROUND

Patients are at risk of developing pressure injuries in the peri-operative setting. Studies evaluating the impact of educational interventions on peri-operative nurses' knowledge and reported practice are scarce. The purpose of this study was to evaluate the effect of a multifaceted intervention on peri-operative nurses' (a) knowledge of pressure injury risks, risk assessment and prevention strategies for patients in the operating suite; and (b) reported practice relating to risk assessment practices and implementation of prevention strategies for patients in the operating suite.

METHODS

A before-after research design was used. A convenience sample of all registered and enrolled nurses employed in two hospitals' operating suites was recruited. A multifaceted intervention was delivered which comprised a short presentation, educational materials and reminder posters. A 48-item survey tool was completed pre-and post-intervention to measure self-reported knowledge and practice.

RESULTS

70 eligible peri-operative nurses completed both surveys. Post-intervention, statistically significant improvements were seen in knowledge of correct descriptions of pressure injury stages (p=0.001); appropriate reassessment for patients with a new pressure injury (p=0.05); appropriate actions for patients with an existing stage 1 (p=0.02) and stage 2 pressure injury (p=0.04). Statistical improvements were also seen in reported practice relating to an increase in the use of a risk assessment tool in conjunction with clinical judgement (p=0.0008); verbal handover of patients' pressure injury risk status from the operating room nurse to the recovery room (p=0.023) and from the recovery room nurse to the postoperative ward nurse (p=0.045). The number of participants reporting use of non-recommended and recommended pressure-relieving strategies was unchanged.

CONCLUSION

A multi-faceted educational intervention can improve some aspects of perioperative nurses' knowledge and reported practice such as risk assessment practices but not others such as use of recommended pressure-relieving devices. Further research is required to ascertain effective interventions which improve all areas of practice and knowledge, particularly in the use of appropriate pressure-relieving devices in order to prevent pressure injuries in surgical patients.

Building theories of knowledge translation interventions: use the entire menu of constructs

Background

In the ongoing effort to develop and advance the science of knowledge translation (KT), an important question has emerged around how theory should inform the development of KT interventions.

Discussion

Efforts to employ theory to better understand and improve KT interventions have until recently mostly involved examining whether existing theories can be usefully applied to the KT context in question. In contrast to this general theory application approach, we propose a ‘menu of constructs’ approach, where individual constructs from any number of theories may be used to construct a new theory. By considering the entire menu of available constructs, rather than limiting choice to the broader level of theories, we can leverage knowledge from theories that would never on their own provide a complete picture of a KT intervention, but that nevertheless describe components or mechanisms relevant to it. We can also avoid being forced to adopt every construct from a particular theory in a one-size-fits-all manner, and instead tailor theory application efforts to the specifics of the situation. Using audit and feedback as an example KT intervention strategy, we describe a variety of constructs (two modes of reasoning, cognitive dissonance, feed forward, desirable difficulties and cognitive load, communities of practice, and adaptive expertise) from cognitive and educational psychology that make concrete suggestions about ways to improve this class of intervention.

Summary

The ‘menu of constructs’ notion suggests an approach whereby a wider range of theoretical constructs, including constructs from cognitive theories with scope that makes the immediate application to the new context challenging, may be employed to facilitate development of more effective KT interventions.

Managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols

BACKGROUND

Management of cancer treatment-related symptoms is an important safety issue given that symptoms can become life-threatening and often occur when patients are at home. With funding from the Canadian Partnership Against Cancer, a pan-Canadian steering committee was established with representation from eight provinces to develop symptom protocols using a rigorous methodology (CAN-IMPLEMENT©). Each protocol is based on a systematic review of the literature to identify relevant clinical practice guidelines. Protocols were validated by cancer nurses from across Canada. The aim of this study is to build an effective and sustainable approach for implementing evidence-informed protocols for nurses to use when providing remote symptom assessment, triage, and guidance in self-management for patients experiencing symptoms while undergoing cancer treatments.

METHODS

A prospective mixed-methods study design will be used. Guided by the Knowledge to Action Framework, the study will involve (a) establishing an advisory knowledge user team in each of three targeted settings; (b) assessing factors influencing nurses' use of protocols using interviews/focus groups and a standardized survey instrument; (c) adapting protocols for local use, ensuring fidelity of the content; (d) selecting intervention strategies to overcome known barriers and implementing the protocols; (e) conducting think-aloud usability testing; (f) evaluating protocol use and outcomes by conducting an audit of 100 randomly selected charts at each of the three settings; and (g) assessing satisfaction with remote support using symptom protocols and change in nurses' barriers to use using survey instruments. The primary outcome is sustained use of the protocols, defined as use in 75% of the calls. Descriptive analysis will be conducted for the barriers, use of protocols, and chart audit outcomes. Content analysis will be conducted on interviews/focus groups and usability testing with comparisons across settings.

DISCUSSION

Given the importance of patient safety, patient-centered care, and delivery of quality services, learning how to effectively implement evidence-informed symptom protocols in oncology healthcare services is essential for ensuring safe, consistent, and effective care for individuals with cancer. This study is likely to have a significant contribution to the delivery of remote oncology services, as well as influence symptom management by patients at home.

"More bang for the buck": exploring optimal approaches for guideline implementation through interviews with international developers

BACKGROUND

Population based studies show that guidelines are underused. Surveys of international guideline developers found that many do not implement their guidelines. The purpose of this research was to interview guideline developers about implementation approaches and resources.

METHODS

Semi-structured telephone interviews were conducted with representatives of guideline development agencies identified in the National Guideline Clearinghouse and sampled by country, type of developer, and guideline clinical indication. Participants were asked to comment on the benefits and resource implications of three approaches for guideline implementation that varied by responsibility: developers, intermediaries, or users.

RESULTS

Thirty individuals from seven countries were interviewed, representing government (n = 12) and professional (n = 18) organizations that produced guidelines for a variety of clinical indications. Organizations with an implementation mandate featured widely inconsistent funding and staffing models, variable approaches for choosing promotional strategies, and an array of dissemination activities. When asked to choose a preferred approach, most participants selected the option of including information within guidelines that would help users to implement them. Given variable mandate and resources for implementation, it was considered the most feasible approach, and therefore most likely to have impact due to potentially broad use.

CONCLUSIONS

While implementation approaches and strategies need not be standardized across organizations, the findings may be used by health care policy makers and managers, and guideline developers to generate strategic and operational plans that optimize implementation capacity. Further research is needed to examine how to optimize implementation capacity by guideline developers, intermediaries and users.

Decreasing time trend in SSI incidence for orthopaedic procedures: surveillance matters!

BACKGROUND

Infection is the most common reason for early revision after hip and knee arthroplasty, and the revision rate is increasing. Surgical site infection (SSI) surveillance data are important to assess the true infection rate. There is little information regarding the potential time trend in SSI incidence following orthopaedic surgery.

AIM

To evaluate whether a time trend exists in SSI incidence due to surveillance following orthopaedic surgery.

METHODS

The SSI rates after hip and knee replacements and osteosynthesis of trochanteric femoral fractures and ankle fractures were recorded prospectively from May 1998 to October 2008 according to the criteria of the US Centers for Disease Control and Prevention. In total, 4177 procedures were analysed, 65.8% of which were performed on female patients. Linear regression was used to analyse trends in SSI rates.

FINDINGS

SSI incidence decreased significantly from 7% in the first year to 3% in the last year; a 57% relative reduction. The duration of surgery was the only significant predictor for infection (P < 0.001) in a logistic regression model that also included age, American Society of Anesthesiologists' score and level of emergency.

CONCLUSION

Surveillance following orthopaedic procedures showed a significant decrease in SSI incidence over the 11-year surveillance period. The causality between surveillance and SSI incidence is difficult to prove, but surveillance with feedback probably influences several procedures that affect the quality of health care, even if duration of surgery is the only significant predictor of this effect.

The Feedback Intervention Trial (FIT)--improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial

INTRODUCTION

Achieving a sustained improvement in hand-hygiene compliance is the WHO's first global patient safety challenge. There is no RCT evidence showing how to do this. Systematic reviews suggest feedback is most effective and call for long term well designed RCTs, applying behavioural theory to intervention design to optimise effectiveness.

METHODS

Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals (16 Intensive Therapy Units [ITU]; 44 Acute Care of the Elderly [ACE] wards) routinely implementing a national cleanyourhands campaign). Intervention-based on Goal & Control theories. Repeating 4 week cycle (20 mins/week) of observation, feedback and personalised action planning, recorded on forms. Computer-generated stepwise entry of all hospitals to intervention. Hospitals aware only of own allocation.

PRIMARY OUTCOME

direct blinded hand hygiene compliance (%).

RESULTS

All 16 trusts (60 wards) randomised, 33 wards implemented intervention (11 ITU, 22 ACE). Mixed effects regression analysis (all wards) accounting for confounders, temporal trends, ward type and fidelity to intervention (forms/month used). INTENTION TO TREAT ANALYSIS: Estimated odds ratio (OR) for hand hygiene compliance rose post randomisation (1.44; 95% CI 1.18, 1.76;p<0.001) in ITUs but not ACE wards, equivalent to 7-9% absolute increase in compliance. PER-PROTOCOL ANALYSIS FOR IMPLEMENTING WARDS: OR for compliance rose for both ACE (1.67 [1.28-2.22]; p<0.001) & ITUs (2.09 [1.55-2.81]; p<0.001) equating to absolute increases of 10-13% and 13-18% respectively. Fidelity to intervention closely related to compliance on ITUs (OR 1.12 [1.04, 1.20]; p = 0.003 per completed form) but not ACE wards.

CONCLUSION

Despite difficulties in implementation, intention-to-treat, per-protocol and fidelity to intervention, analyses showed an intervention coupling feedback to personalised action planning produced moderate but significant sustained improvements in hand-hygiene compliance, in wards implementing a national hand-hygiene campaign. Further implementation studies are needed to maximise the intervention's effect in different settings.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN65246961.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.

Can hospital audit teams identify case management problems, analyse their causes, identify and implement improvements? A cross-sectional process evaluation of obstetric near-miss case reviews in Benin

Background

Obstetric near-miss case reviews are being promoted as a quality assurance intervention suitable for hospitals in low income countries. We introduced such reviews in five district, regional and national hospitals in Benin, West Africa. In a cross-sectional study we analysed the extent to which the hospital audit teams were able to identify case management problems (CMPs), analyse their causes, agree on solutions and put these solutions into practice.

Methods

We analysed case summaries, women’s interview transcripts and audit minutes produced by the audit teams for 67 meetings concerning one woman with near-miss complications each. We compared the proportion of CMPs identified by an external assessment team to the number found by the audit teams. For the latter, we described the CMP causes identified, solutions proposed and implemented by the audit teams.

Results

Audit meetings were conducted regularly and were well attended. Audit teams identified half of the 714 CMPs; they were more likely to find managerial ones (71%) than the ones relating to treatment (30%). Most identified CMPs were valid. Almost all causes of CMPs were plausible, but often too superficial to be of great value for directing remedial action. Audit teams suggested solutions, most of them promising ones, for 38% of the CMPs they had identified, but recorded their implementation only for a minority (8.5%).

Conclusions

The importance of following-up and documenting the implementation of solutions should be stressed in future audit interventions. Tools facilitating the follow-up should be made available. Near-miss case reviews hold promise, but their effectiveness to improve the quality of care sustainably and on a large scale still needs to be established.

Caries treatment in a dental practice-based research network: movement toward stated evidence-based treatment

OBJECTIVES

Practice-based research networks (PBRNs) provide a venue to foster evidence-based care. We tested the hypothesis that a higher level of participation in a dental PBRN is associated with greater stated change toward evidence-based practice.

METHODS

A total of 565 dental PBRN practitioner-investigators completed a baseline questionnaire entitled 'Assessment of Caries Diagnosis and Treatment'; 405 of these also completed a follow-up questionnaire about treatment of caries and existing restorations. Certain questions (six treatment scenarios) were repeated at follow-up a mean (SD) of 36.0 (3.8) months later. A total of 224 were 'full participants' (enrolled in clinical studies and attended at least one network meeting); 181 were 'partial participants' (did not meet 'full' criteria).

RESULTS

From 10% to 62% of practitioners were 'surgically invasive' at baseline, depending on the clinical scenario. Stated treatment approach was significantly less invasive at follow-up for four of six items. Change was greater among full participants and those with a more-invasive approach at baseline, with an overall pattern of movement away from the extremes.

CONCLUSIONS

These results are consistent with a preliminary conclusion that network participation fostered movement of scientific evidence into routine practice. PBRNs may foster movement of evidence into everyday practice as practitioners become engaged in the scientific process.

Effectiveness and efficiency of a practice accreditation program on cardiovascular risk management in primary care: study protocol of a clustered randomized trial

BACKGROUND

Cardiovascular risk management is largely provided in primary healthcare, but not all patients with established cardiovascular diseases receive preventive treatment as recommended. Accreditation of healthcare organizations has been introduced across the world with a range of aims, including the improvement of clinical processes and outcomes. The Dutch College of General Practitioners has launched a program for accreditation of primary care practices, which focuses on chronic illness care. This study aims to determine the effectiveness and efficiency of a practice accreditation program, focusing on patients with established cardiovascular diseases.

METHODS/DESIGN

We have planned a two-arm cluster randomized trial with a block design. Seventy primary care practices will be recruited from those who volunteer to participate in the practice accreditation program. Primary care practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician. The intervention group (n = 35 practices) will be instructed to focus improvement on cardiovascular risk management. The control group will be instructed to focus improvement on other domains in the first year of the program. Baseline and follow-up measurements at 12 months after receiving the accreditation certificate are based on a standardized version of the audit in the practice accreditation program. Primary outcomes include controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication. Secondary outcomes are 15 process indicators and two outcome indicators of cardiovascular risk management, self-reported achievement of improvement goals and perceived unintended consequences. The intention to treat analysis is statistically powered to detect a difference of 10% on primary outcomes. The economic evaluation aims to determine the efficiency of the program and investigates the relationship between costs, performance indicators, and accreditation.

DISCUSSION

It is important to gain more information about the effectiveness and efficiency of the practice accreditation program to assess if participation is worthwhile regarding the quality of cardiovascular risk management. The results of this study will help to develop the practice accreditation program for primary care practices.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Improving patient-centeredness of fertility care using a multifaceted approach: study protocol for a randomized controlled trial

BACKGROUND

Beside traditional outcomes of safety and (cost-)effectiveness, the Institute of Medicine states patient-centeredness as an independent outcome indicator to evaluate the quality of healthcare. Providing patient-centered care is important because patients want to be heard for their ideas and concerns. Healthcare areas associated with high emotions and intensive treatment periods could especially benefit from patient-centered care. How care can become optimally improved in patient-centeredness is unknown. Therefore, we will conduct a study in the context of Dutch fertility care to determine the effects of a multifaceted approach on patient-centeredness, patients' quality of life (QoL) and levels of distress. Our aims are to investigate the effectiveness of a multifaceted approach and to identify determinants of a change in the level of patient-centeredness, patients' QoL and distress levels. This paper presents the study protocol.

METHODS/DESIGN

In a cluster-randomized trial in 32 Dutch fertility clinics the effects of a multifaceted approach will be determined on the level of patient-centeredness (Patient-centredness Questionnaire - Infertility), patients' QoL (FertiQoL) and levels of distress (SCREENIVF). The multifaceted approach includes audit and feedback, educational outreach visits and patient-mediated interventions. Potential determinants of a change in patient-centeredness, patients' QoL and levels of distress will be collected by an addendum to the patients' questionnaire and a professionals' questionnaire. The latter includes the Organizational Culture Assessment Instrument about the clinic's culture as a possible determinant of an increase in patient-centered care.

DISCUSSION

The study is expected to yield important new evidence about the effects of a multifaceted approach on levels of patient-centeredness, patients' QoL and distress in fertility care. Furthermore, determinants associated with a change in these outcome measures will be studied. With knowledge of these results, patient-centered care and thus the quality of healthcare can be improved. Moreover, the results of this study could be useful for similar initiatives to improve the quality of care delivery. The results of this project are expected at the end of 2013.

TRIAL REGISTRATION

Clinicialtrials.gov NCT01481064.

Feedback reporting of survey data to healthcare aides

Background

This project occurred during the course of the Translating Research in Elder Care (TREC) program of research. TREC is a multilevel and longitudinal research program being conducted in the three Canadian Prairie Provinces of Alberta, Saskatchewan, and Manitoba. The main purpose of TREC is to increase understanding about the role of organizational context in influencing knowledge use in residential long-term care settings. The purpose of this study was to evaluate healthcare aides’ (HCAs) perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practice) from the TREC survey they had recently completed.

Methods

A convenience sample of 7 of the 15 nursing homes participating in the TREC research program in Alberta were invited to participate. Specific facility-level summary data were provided to each facility in the form of a one-page poster report. Two weeks following delivery of the report, a convenience sample of HCAs was surveyed using one-to-one structured interviews.

Results

One hundred twenty-three HCAs responded to the evaluation survey. Overall, HCAs’ opinions about presentation of the feedback report and the understandability, usability, and usefulness of the content were positive. For each report, analysis of data and production and inspection of the report took up to one hour. Information sessions to introduce and explain the reports averaged 18 minutes. Two feedback reports (minimum) were supplied to each facility at a cost of CAN$2.39 per report, for printing and laminating.

Conclusions

This study highlights not only the feasibility of producing understandable, usable, and useful feedback reports of survey data but also the value and importance of providing feedback to survey respondents. More broadly, the findings suggest that modest strategies may have a positive and desirable effect in participating sites.

Clinical audits in a postgraduate general practice training program: an evaluation of 8 years' experience

Background

Clinical audit can be of valuable assistance to any program which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at evaluating audits' effectiveness, valuable opportunities will be overlooked. Clinical audit projects are required as a part of the formative assessment of trainees in the Family Medicine Residency Program (FMRP) in Kuwait. This study was undertaken to draw a picture of trainees' understanding of the audit project with attention to the knowledge of audit theory and its educational significance and scrutinize the difficulties confronted during the experience.

Methodology/Principal Findings

The materials included the records of 133 audits carried out by trainees and 165 post course questionnaires carried out between 2004 and 2011. They were reviewed and analyzed. The majority of audit projects were performed on diabetic (44.4%) and hypertensive (38.3%) care. Regarding audits done on diabetic care, they were carried out to assess doctors' awareness about screening for smoking status (8.6%), microalbuminuria (19.3%), hemoglobin A1c (15.5%), retinopathy (10.3%), dyslipidemia (15.8%), peripheral neuropathy (8.8%), and other problems (21.7%). As for audits concerning hypertensive care, they were carried out to assess doctors' awareness about screening for smoking status (38.0%), obesity (26.0%), dyslipidemia (12.0%), microalbuminuria (10.0%) and other problems (14.0%). More than half the participants (68.48%) who attended the audit course stated that they ‘definitely agreed’ about understanding the meaning of clinical audit. Most of them (75.8%) ‘definitely agreed’ about realizing the importance of clinical audit in improving patients' care. About half (49.7%) of them ‘agreed’ that they can distinguish between ‘criteria’ and ‘standards’.

Conclusion

The eight years of experience were beneficial. Trainees showed a good understanding of the idea behind auditing the services provided. They demonstrated their ability to improve the care given in health centers in which these projects were undertaken.

Judging whether a patient is actually improving: more pitfalls from the science of human perception

Fallible human judgment may lead clinicians to make mistakes when assessing whether a patient is improving following treatment. This article provides a narrative review of selected studies in psychology that describe errors that potentially apply when a physician assesses a patient's response to treatment. Comprehension may be distorted by subjective preconceptions (lack of double blinding). Recall may fail through memory lapses (unwanted forgetfulness) and tacit assumptions (automatic imputation). Evaluations may be further compromised due to the effects of random chance (regression to the mean). Expression may be swayed by unjustified overconfidence following conformist groupthink (group polarization). An awareness of these five pitfalls may help clinicians avoid some errors in medical care when determining whether a patient is improving.

Translating knowledge to practice: optimizing the use of guidelines

Guidelines support health care decision-making but continue to be underused, therefore more research is needed on how they can be better developed and implemented. The same is true of mental health care, for which there is recent growing interest in improving care delivery and associated outcomes by optimizing the use of mental health care guidelines. This editorial describes the key concepts from accumulated research on guideline implementation to suggest a number of avenues for research on implementation of mental health care guidelines.

Web-based mammography audit feedback

OBJECTIVE

Interpreting screening mammography accurately is challenging and requires ongoing education to maintain and improve interpretative skills. Recognizing this, many countries with organized breast screening programs have developed audit and feedback systems using national performance data to help radiologists assess and improve their skills. We developed and tested an interactive Website to provide screening and diagnostic mammography audit feedback with comparisons to national and regional benchmarks.

MATERIALS AND METHODS

Radiologists who participate in three Breast Cancer Surveillance Consortium registries in the United States were invited during 2009 and 2010 to use a Website that provides tabular and graphical displays of mammography audit reports with comparisons to national and regional performance measures. We collected data about the use and perceptions of the Website.

RESULTS

Thirty-five of 111 invited radiologists used the Website from one to five times in a year. The most popular measure was sensitivity for both screening and diagnostic mammography, whereas a table with all measures was the most visited page. Of the 13 radiologists who completed the postuse survey, all found the Website easy to use and navigate, 11 found the benchmarks useful, and nine reported that they intended to improve a specific outcome measure that year.

CONCLUSION

An interactive Website to provide customized mammography audit feedback reports to radiologists has the potential to be a powerful tool in improving interpretive performance. The conceptual framework of customized audit feedback reports can also be generalized to other imaging tests.

Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action

AIM

To compare overall unit-level pressure ulcer (PU) prevalence, hospital-acquired pressure ulcer (HAPU) prevalence and prevention strategies, as well as nurse staffing and workload in two hospitals in Sweden with data from the USA.

METHODS

Medical and surgical units in a university hospital and a general hospital in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarking registry. All adult inpatients in university hospital (n = 630), general hospital (n = 253) and CALNOC hospitals (n = 3506) were included in the study. Outcome indicators were pressure ulcer prevalence for all types (PU) and HAPU prevalence, specifically. Process indicators were risk assessment and PU prevention strategies. Structure indicators were nurse staffing (hours of care, and skill mix) and workload (admissions, discharges and transfers).

RESULTS

The prevalence of PU (categories 1-4) was 17.6% (university hospital) and 9.5% (general hospital) compared with 6.3-6.7% in the CALNOC sample. The prevalence of full thickness HAPU (categories 3 and 4) was 2.7% (university hospital) and 2.0% (general hospital) compared with 0-0.5% in the CALNOC sample. Risk and skin assessment varied between 6% and 60% in the Swedish hospitals compared with 100% in the CALNOC sample. Total hours per patient day were 8.4 in both Swedish hospitals and 9.5 to 9.8 in the CALNOC hospitals

CONCLUSIONS

The findings suggest a link between processes of care and outcomes that is exciting to observe internationally and suggest the opportunity to expedite performance improvement through global benchmarking. Using HAPU as a complement to point prevalence of PU in Sweden has revealed this indicator as a more valid measure for patient care quality.

High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved?

The safety of medication use in primary care is an area of increasing concern for health systems internationally. Systematic reviews estimate that 3-4% of all unplanned hospital admissions are due to preventable drug-related morbidity, the majority of which have been attributed to shortcomings in the prescribing and monitoring stages of the medication use process. We define high-risk prescribing as medication prescription by professionals, for which there is evidence of significant risk of harm to patients, and which should therefore either be avoided or (if avoidance is not possible) closely monitored and regularly reviewed for continued appropriateness. Although prevalence estimates vary depending on the instrument used, cross-sectional studies conducted in primary care equivocally show that it is common and there is evidence that it can be reduced. Quality improvement strategies, such as clinical decision support, performance feedback and pharmacist-led interventions have been shown to be effective in reducing prescribing outcomes but evidence of improved patient outcomes remains limited. The increasing implementation of electronic medical records in primary care offer new opportunities to combine different strategies to improve medication safety in primary care and to integrate services provided by different stakeholders. In this review article, we describe the spectrum of high-risk medication use in primary care, review approaches to its measurement and summarize research into its prevalence. Based on previously developed interventions to change professional practice, we propose a systematic approach to improve the safety of medication use in primary care and highlight areas for future research.

Advances in childhood immunisation in South Africa: where to now? Programme managers' views and evidence from systematic reviews

Background

The Expanded Programme on Immunisation (EPI) is one of the most powerful and cost-effective public health programmes to improve child survival. We assessed challenges and enablers for the programme in South Africa, as we approach the 2015 deadline for the Millennium Development Goals.

Methods

Between September 2009 and September 2010 we requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. We collated their responses and searched for systematic reviews on the effectiveness of the proposed solutions; in the Health Systems Evidence, Cochrane Library, and PubMed electronic databases. We screened the search outputs, selected systematic reviews, extracted data, and assessed the quality of included reviews (using AMSTAR) and the quality of the evidence (using GRADE) in duplicate; resolving disagreements by discussion and consensus.

Results

Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes, respectively. The findings from reliable systematic reviews indicate that interactive educational meetings, audit and feedback, and supportive supervision improve healthcare worker performance. Structured and interactive communication tools probably increase parents’ understanding of immunisation; and reminders and recall, use of community health workers, conditional cash transfers, and mass media interventions probably increase immunisation coverage. Finally, a national social health insurance scheme is a potential EPI financing mechanism; however, given the absence of high-quality evidence of effects, its implementation should be pilot-tested and the impacts and costs rigorously monitored.

Conclusion

In line with the Millennium Development Goals, we have to ensure that our children’s right to health, development and survival is respected, protected and promoted. EPI is central to this vision. We found numerous promising strategies for improving EPI performance in South Africa. However, their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation. The strength of our approach comes from having a strong framework for interventions before looking for systematic reviews. Without a framework, we would have been driven by what reviews have been done and what is easily researchable; rather than the values and preferences of key immunisation stakeholders.