Audit and feedback: effects on professional practice and healthcare outcomes

How Can Implementation Science Improve the Care of Familial Hypercholesterolaemia?

PURPOSE OF REVIEW

Describe the application of implementation science to improve the detection and management of familial hypercholesterolaemia.

RECENT FINDINGS

Gaps between evidence and practice, such as underutilization of genetic testing, family cascade testing, failure to achieve LDL-cholesterol goals and low levels of knowledge and awareness, have been identified through clinical registry analyses and clinician surveys. Implementation science theories, models and frameworks have been applied to assess barriers and enablers in the literature specific to local contextual factors (e.g. stages of life). The effect of implementation strategies to overcome these factors has been evaluated; for example, automated identification of individuals with FH or training and education to improve statin adherence. Clinical registries were identified as a key infrastructure to monitor, evaluate and sustain improvements in care. The expansion in evidence supporting the care of familial hypercholesterolaemia requires a similar expansion of efforts to translate new knowledge into clinical practice.

Toward Improving Patient Equity in a Pediatric Emergency Department: A Framework for Implementation

Disparities in health care delivery and health outcomes for patients in the emergency department (ED) by race, ethnicity, and language for care (REaL) are common and well documented. Addressing inequities from structural racism, implicit bias, and language barriers can be challenging, and there is a lack of data on effective interventions. We describe the implementation of a multifaceted equity improvement strategy in a pediatric ED using Kotter's model for change as a framework to identify the key drivers. The main elements included a data dashboard with quality metrics stratified by patient self-reported REaL to visualize disparities, a staff workshop on implicit bias and microaggressions, and several clinical and operational tools that highlight equity. Our next steps include refining and repeating interventions and tracking important patient outcomes, including timely pain treatment, triage assessment, diagnostic evaluations, and interpreter use, with the overall goal of improving patient equity by REaL over time. This article presents a roadmap for a disparity reduction intervention, which can be part of a multifaceted approach to address health equity in EDs.

Prescribing patterns of SGLT-2 inhibitors for patients with heart failure: A two-center analysis

Background

Sodium glucose co-transporter 2 inhibitors (SGLT2i) have been proven to reduce the combined risk of cardiovascular death and hospitalizations in patients with heart failure (HF), irrespective of the presence or absence of diabetes. Despite class 1 and class 2A recommendations for their usage in HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) respectively by the American College of Cardiology, their prescription rate has remained low.

Objective

The aim of this study is to analyze SGLT2i prescription patterns at two academic institutions, with the goal of identifying barriers to implementation.

Design

A two-center retrospective analysis was conducted on patients ≥18 years old with a diagnosis of heart failure who were admitted to one of two hospital systems between 5/1/21 and 5/31/22. Patients with an eGFR ≥20 mL/min/1.73m2 and BNP ≥ 100 pg/mL were included.

Results

SGLT2i was prescribed in only 19 out of 1081 HFpEF patients (1.8 %) and 51 out of 1596 HFrEF patients (3.2 %). A majority of SGLT2i prescriptions for the HFpEF population came from general medicine services (57.9 %) after obtaining approval from a cardiologist, which was required at our institutions. Adverse effects such as hypoglycemia and urinary tract infections were not significantly associated with SGLT2i use.

Conclusions

Despite proven benefits of this class of medications as witnessed in large-scale clinical trials, the implementation of this drug class continues to be low.

Integrating Tobacco Use Assessment and Treatment in the Oncology Setting: Quality Improvement Results from the Georgetown Lombardi Smoking Treatment and Recovery Program

As part of the NCI’s Cancer Center Cessation (C3i) initiative, we initiated, expanded, and maintained an evidence-based tobacco treatment program at the Georgetown Lombardi Comprehensive Cancer Center. We present a quality improvement (QI) assessment of the implementation process and patient-level outcomes. At two hematology/oncology outpatient clinical sites, five oncology-based teams (clinical administrators, clinical staff, pharmacy, information technology, and tobacco treatment staff) developed implementation strategies for opt-out patient assessment and enrollment, centralized tobacco treatment, audit, feedback, and staff training. Among eligible patients (tobacco use in ≤30 days), we assessed demographic, clinical, and tobacco-related characteristics to examine predictors of enrollment (baseline completed), treatment engagement (≥one sessions completed), and self-reported 7-day abstinence (6 months post-enrollment). Across both sites, medical assistants screened 19,344 (82.4%) patients for tobacco use, which identified 1345 (7.0%) current tobacco users, in addition to 213 clinician referrals. Of the 687/1256 (54.7%) eligible patients reached, 301 (43.8%) enrolled, and 199 (29.0%) engaged in treatment, of whom 74.5% were African American and 68% were female. At the larger site, significant multivariate predictors of enrollment included African American race (vs. white/other) and clinician referral (vs. MA assessment). Treatment engagement was predicted by greater nicotine dependence, and abstinence (27.4%) was predicted by greater treatment engagement. In summary, the systematic utilization of multiple oncology-based teams and implementation strategies resulted in the development and maintenance of a high-quality, population-based approach to tobacco treatment. Importantly, these strategies addressed inequities in tobacco treatment, as the program reached and engaged a majority-African-American patient population. Finally, the opt-out patient assessment strategy has been implemented in multiple oncology settings at MedStar Health through the Commission on Cancer’s Just Ask program.

Common Elements Approaches to Implementation Research and Practice: Methods and Integration with Intervention Science

We propose that common elements approaches can advance implementation research and practice and facilitate pragmatic use of intervention and implementation evidence. Common elements are practices or processes frequently shared by interventions or implementations. Traditional common elements methodologies use synthesis, distillation, and statistics to describe and evaluate the merit of common ingredients in effective interventions. Recent developments include identifying and testing common configurations of elements, processes, and context variables across the literature of effective interventions and implementations. While common elements thinking has grown popular in intervention science, it has rarely been utilized in implementation science, and specifically, combined with the intervention literature. The goals of this conceptual methodology paper are to (1) provide an overview of the common elements concept and how it may advance implementation research and usability for practice, (2) give a step-by-step guide to systematic common elements reviews that synthesizes and distills the intervention and implementation literature together, and (3) offer recommendations for advancing element-level evidence in implementation science. A narrative review of the common elements literature was conducted with attention to applications to implementation research. A six-step guide to using an advanced common elements methodology was provided. Examples of potential results are presented, along with a review of the implications for implementation research and practice. Finally, we reviewed methodological limitations in current common elements approaches, and identified steps towards realizing their potential. Common elements methodologies can (a) synthesize and distill the implementation science literature into practical applications, (b) generate evidence-informed hypotheses about key elements and determinants in implementation and intervention processes and mechanisms, and (c) promote evidence-informed precision tailoring of intervention and implementation to context. To realize this potential, common elements approaches need improved reporting of details from both successful and unsuccessful intervention and implementation research, more data availability, and more testing and investigation of causal processes and mechanisms of change from diverse theories.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00077-4.

Impact of a quality improvement intervention on the incidence of surgical site infection in patients undergoing colorectal surgery: Pre-test-post-test design

AIMS AND OBJECTIVES

The aim of this study was to measure the impact of a complex quality improvement intervention on the incidence of SSI in patients undergoing elective colorectal surgery.

BACKGROUND

Surgical site infections are a major postoperative complication for patients undergoing colorectal surgery. Prevention of SSIs necessitates a complex intervention requiring many elements to be in place to ensure the successful implementation of prevention measures.

DESIGN

This study was a non-equivalent pre-test post-test design where consecutive patients undergoing colorectal surgery were surveyed for surgical site infections for 30 days postoperatively and is reported using the SQUIRE 2.0.

METHODS

A baseline cohort of patients was retrospectively reviewed in a single centre to ascertain the surgical site infection incidence rate in the first 6 months of 2018 (T0) and prospectively at two 6-month time periods in 2019 (T1, T2) following the introduction of a complex intervention. There were 311 patients included across three time periods.

RESULTS

There was a notable decrease in surgical site infection incidence rates from baseline over the course of the study. Univariate analysis identified Body Mass Index, a wound contamination classification of dirty or contaminated, duration of surgery >75th percentile and a National Healthcare Safety Network risk index score of 3 as factors that significantly increase the probability of developing a surgical site infection. Multivariate analysis identified duration of surgery and body mass index increased the probability of an SSI. The results of the logistical regression model found that there was a significant reduction in the probability of an SSI between T0 and T2.

CONCLUSIONS

The implementation of a complex intervention led to a reduction in the incidence of surgical site infections and improved implementation of evidence-based practices as part of a care bundle in relation to the prevention of surgical site infections in patients undergoing elective colorectal surgery.

RELEVANCE TO CLINICAL PRACTICE

A multicomponent multidisciplinary complex intervention as part of a quality improvement project can successfully reduce the incidence rates of surgical site infections in patients who require elective colorectal surgery. Normalisation Process Theory provides guidance and support in implementing complex interventions for the prevention of surgical site infection.

PATIENT OR PUBLIC CONTRIBUTION

Patients provided post-discharge information on their wound healing as part of the surveillance component of the intervention. Five patients reviewed and provided feedback on a patient information booklet which was developed from this quality improvement intervention. A multidisciplinary steering group guided all stages of the project.

Regular measurement is essential but insufficient to improve quality of healthcare

Ambrose Agweyu and colleagues argue that large scale improvements in quality of healthcare require strong change management as well as health information systems that can provide continuous and rapid feedback

Virtual Oral Health across Canada: A Critical Comparative Analysis of Clinical Practice Guidances during the COVID-19 Pandemic

During the COVID-19 pandemic, teledentistry was suggested as a cost-effective and promising approach to improve access to oral health care. In response, Canadian provincial and territorial dental regulatory authorities (DRAs) published teledentistry-related clinical practice guidances (TCPGs). However, an in-depth comparison between them is needed to understand their gaps and commonalities so as to inform research, practice, and policy. This review aimed to provide a comprehensive analysis of TCPGs published by Canadian DRAs during the pandemic. A critical comparative analysis of these TCPGs published between March 2020 and September 2022 was conducted. Two members of the review team screened the official websites of dental regulatory authorities (DRAs) to identify TCPGs and performed data extraction. Among Canada's 13 provinces and territories, only four TCPGs were published during the relevant time period. There were some similarities and differences in these TCPGs, and we identified gaps pertaining to communication tools and platforms, and measures to safeguard patients' privacy and confidentiality. The insights from this critical comparative analysis and the unified workflow on teledentistry can aid DRAs in their development of new or an improvement to existing TCPGs or the development of nationwide TCP guidelines on teledentistry.

Development of PIVOT with MI: A motivational Interviewing-Based vaccine communication training for pediatric clinicians

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents' most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92 % viewed an introductory video module, 93 % attended or viewed a baseline synchronous training, 82 % attended or viewed a 1st refresher training, and 77 % attended or viewed a 2nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n = 100), >95 % of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians.

From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa

INTRODUCTION

Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa.

METHODS

Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation.

RESULTS

Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice.

CONCLUSION

This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.

Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey

BACKGROUND

Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism.

METHODS

In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics.

RESULTS

A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness.

CONCLUSION

The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute-care hospitals in prioritization and implementation of strategies to prevent healthcare-associated infections through hand hygiene. This document updates the Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene, published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Implementation of a relapse prevention program among smokers undergoing arthroplasty: lessons learned

BACKGROUND

Surgery is a potent motivator to help people quit smoking to reduce the risk of complications. Many patients who smoke receive tobacco cessation counseling prior to surgery and are able to quit, but do not receive the same resources after surgery and often resume smoking.

METHODS

We present a case study describing the recruitment process, study components, and lessons learned from StayQuit, a comprehensive relapse prevention program designed to prevent relapse after arthroplasty. Lessons learned were examined post hoc to determine challenges related to program implementation, using existing study procedures and information collected.

RESULTS

While a comprehensive postoperative relapse prevention program may be beneficial to patients, implementation of StayQuit is unlikely to be feasible under current circumstances. The primary challenges to successful implementation of StayQuit focused on themes of lack of engagement in the preoperative Orthopedic Surgery Quit Smoking Program (OSQSP) and an environment unfavorable to in-person enrollment on the day of surgery.

CONCLUSIONS

Postoperative relapse prevention programs may be beneficial for patients who quit smoking prior to elective surgery. To help guide implementation, it is important to consider surgeon behavior, the collaboration of clinical and non-clinical teams, and best practices for study enrollment in surgical settings.

Consensus on Prioritisation of Actions for Reducing the Environmental Impact of a Large Tertiary Hospital: Application of the Nominal Group Technique

Hospitals are the largest greenhouse gas producers within the Australian healthcare sector due to the large amounts of energy, resource utilization, equipment and pharmaceuticals required to deliver care. In order to reduce healthcare emissions, healthcare services must take multiple actions to address the broad range of emissions produced when delivering patient care. The goal of this study was to seek consensus on the priority actions needed to reduce the environmental impact of a tertiary Australian hospital. A nominal group technique was utilized within a multidisciplinary, executive-led environmental sustainability committee to find consensus on the 62 proposed actions to reduce the environmental impact of a tertiary Australian hospital. Thirteen participants joined an online workshop during which an educational presentation was delivered, 62 potential actions were privately ranked according to two domains of 'amenability to change' and 'scale of climate impact' and a moderated group discussion ensued. The group achieved verbal consensus on 16 actions that span staff education, procurement, pharmaceuticals, waste, transport and advocacy on all-electric capital works upgrades. In addition, the individual ratings of potential actions according to each domain were ranked and shared with the group. Despite a large number of actions and varied perspectives within the group, the nominal group technique can be used to focus a hospital leadership group on priority actions to improve environmental sustainability.

Effective peer review audit and identification of the surgeon outlier

BACKGROUND

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit.

METHODS

All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT).

RESULTS

A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored.

CONCLUSION

The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Thought Leader Perspectives on the Benefits, Barriers, and Enablers for Routinely Collected Electronic Health Data to Support Professional Development: Qualitative Study

BACKGROUND

Hospitals routinely collect large amounts of administrative data such as length of stay, 28-day readmissions, and hospital-acquired complications; yet, these data are underused for continuing professional development (CPD). First, these clinical indicators are rarely reviewed outside of existing quality and safety reporting. Second, many medical specialists view their CPD requirements as time-consuming, having minimal impact on practice change and improving patient outcomes. There is an opportunity to build new user interfaces based on these data, designed to support individual and group reflection. Data-informed reflective practice has the potential to generate new insights about performance, bridging the gap between CPD and clinical practice.

OBJECTIVE

This study aims to understand why routinely collected administrative data have not yet become widely used to support reflective practice and lifelong learning.

METHODS

We conducted semistructured interviews (N=19) with thought leaders from a range of backgrounds, including clinicians, surgeons, chief medical officers, information and communications technology professionals, informaticians, researchers, and leaders from related industries. Interviews were thematically analyzed by 2 independent coders.

RESULTS

Respondents identified visibility of outcomes, peer comparison, group reflective discussions, and practice change as potential benefits. The key barriers included legacy technology, distrust with data quality, privacy, data misinterpretation, and team culture. Respondents suggested recruiting local champions for co-design, presenting data for understanding rather than information, coaching by specialty group leaders, and timely reflection linked to CPD as enablers to successful implementation.

CONCLUSIONS

Overall, there was consensus among thought leaders, bringing together insights from diverse backgrounds and medical jurisdictions. We found that clinicians are interested in repurposing administrative data for professional development despite concerns with underlying data quality, privacy, legacy technology, and visual presentation. They prefer group reflection led by supportive specialty group leaders, rather than individual reflection. Our findings provide novel insights into the specific benefits, barriers, and benefits of potential reflective practice interfaces based on these data sets. They can inform the design of new models of in-hospital reflection linked to the annual CPD planning-recording-reflection cycle.

Barriers and facilitators to guideline-recommended care of benign paroxysmal positional vertigo in the ED: a qualitative study using the theoretical domains framework

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a common presentation to the ED. Evidence suggests low adherence to guideline-recommended care, but the reasons underlying this are poorly understood. This study used the theoretical domains framework (TDF) to explore the barriers and facilitators to medical and physiotherapy clinical practices in the management of BPPV in an Australian metropolitan ED.

METHODS

From May to December 2021, semistructured interviews were conducted with 13 medical staff and 13 physiotherapists who worked at an ED in Melbourne, Australia. Interviews used the TDF to explore the perceived barriers and facilitators to the delivery of guideline-recommended assessment and treatment techniques for BPPV. Data were analysed thematically to identify relevant domains and generate themes and belief statements.

RESULTS

Fifteen belief statements representing eight domains of the TDF were identified as key factors in the management of BPPV in the ED. The most prominent domains were knowledge and skills due to their conflicting belief statements between professions concerning education, skill development and self-confidence; memory, attention and decision processes for the perceived complexity of the presentation including difficulty recalling diagnostic and treatment techniques; and environmental context and resources for their shared belief statements concerning time and workload pressures. The availability of vestibular physiotherapy was considered both a barrier and facilitator to the delivery of recommended care by medical staff, but a barrier to independent practice as it unintentionally limited the opportunities for skill development in medical staff.

CONCLUSION

Several modifiable barriers and facilitators to the management of BPPV in the ED have been identified. Differences were observed between the professional groups, and these findings will guide a future intervention to improve the use of guideline-recommended assessment and treatment techniques for BPPV in ED.

Implemented machine learning tools to inform decision-making for patient care in hospital settings: a scoping review

OBJECTIVES

To identify ML tools in hospital settings and how they were implemented to inform decision-making for patient care through a scoping review. We investigated the following research questions: What ML interventions have been used to inform decision-making for patient care in hospital settings? What strategies have been used to implement these ML interventions?

DESIGN

A scoping review was undertaken. MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR) were searched from 2009 until June 2021. Two reviewers screened titles and abstracts, full-text articles, and charted data independently. Conflicts were resolved by another reviewer. Data were summarised descriptively using simple content analysis.

SETTING

Hospital setting.

PARTICIPANT

Any type of clinician caring for any type of patient.

INTERVENTION

Machine learning tools used by clinicians to inform decision-making for patient care, such as AI-based computerised decision support systems or "'model-based'" decision support systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient and study characteristics, as well as intervention characteristics including the type of machine learning tool, implementation strategies, target population. Equity issues were examined with PROGRESS-PLUS criteria.

RESULTS

After screening 17 386 citations and 3474 full-text articles, 20 unique studies and 1 companion report were included. The included articles totalled 82 656 patients and 915 clinicians. Seven studies reported gender and four studies reported PROGRESS-PLUS criteria (race, health insurance, rural/urban). Common implementation strategies for the tools were clinician reminders that integrated ML predictions (44.4%), facilitated relay of clinical information (17.8%) and staff education (15.6%). Common barriers to successful implementation of ML tools were time (11.1%) and reliability (11.1%), and common facilitators were time/efficiency (13.6%) and perceived usefulness (13.6%).

CONCLUSIONS

We found limited evidence related to the implementation of ML tools to assist clinicians with patient healthcare decisions in hospital settings. Future research should examine other approaches to integrating ML into hospital clinician decisions related to patient care, and report on PROGRESS-PLUS items.

FUNDING

Canadian Institutes of Health Research (CIHR) Foundation grant awarded to SES and the CIHR Strategy for Patient Oriented-Research Initiative (GSR-154442). SCOPING REVIEW REGISTRATION: https://osf.io/e2mna.

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study

OBJECTIVES

To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process.

METHODS

A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities.

RESULTS

Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis.

CONCLUSION

Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

The slow de-implementation of non-evidence-based treatments in low back pain hospital care-Trends in treatments using Dutch hospital register data from 1991 to 2018

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide and has an excessive societal burden. Accumulating evidence has shown that some medical approaches such as imaging in absence of clear indications, medication and some invasive treatments may contribute to the problem rather than alleviating it.

OBJECTIVES

To determine the extent of de-implementation of non-evidence-based hospital treatments for LBP care in the Netherlands in the last three decades.

METHODS

Using a register-based population-level observational study with Dutch hospital data, providing a nearly complete coverage of hospital admissions in the Netherlands in 1991-2018, we assessed five frequently applied non-evidence-based hospital treatments for LBP. Time trends in treatment use (absolute and per 100,000 inhabitants) were plotted and analysed using Poisson regression.

RESULTS

The use of bed rest for non-specific LBP and hernia nuclei pulposi, and discectomy for spinal stenosis decreased 91%, 81% and 86% since the availability of evidence/guidelines, respectively. De-implementation, beyond 84%, was reached after 18 and 17 years for bed rest for non-specific LBP and discectomy respectively, while it was not reached after 28 years for bed rest for hernia nuclei pulposi. For spinal fusion and invasive pain treatment, there was an initial increase followed by a reduction. Overall, these treatments reduced by 85% and 75%, respectively.

CONCLUSIONS

In the Netherlands, de-implementation of five non-recommended hospital LBP treatments, if at all, took several decades. Although de-implementation was substantial, slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to many patients in Dutch hospitals.

SIGNIFICANCE

Medically intensive approaches to low-back pain care contribute to the high societal burden of this disease. There have been calls to avoid such care. Using Dutch hospital data, we showed that de-implementation of five non-recommended hospital low-back pain treatments, if at all, took several decades (i.e. ≥17 years) after availability of evidence and guidelines. Slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to hospital patients; better ways for de-implementation of non-evidence-based care are needed.

Best practices to reduce COVID-19 in group homes for individuals with serious mental illness and intellectual and developmental disabilities: Protocol for a hybrid type 1 effectiveness-implementation cluster randomized trial

BACKGROUND

People with serious mental illness (SMI) and intellectual disabilities and/or developmental disabilities (ID/DD) living in group homes (GHs) and residential staff are at higher risk for COVID-19 infection, hospitalization, and death compared with the general population.

METHODS

We describe a hybrid type 1 effectiveness-implementation cluster randomized trial to assess evidence-based infection prevention practices to prevent COVID-19 for residents with SMI or ID/DD and the staff in GHs. The trial will use a cluster randomized design in 400 state-funded GHs in Massachusetts for adults with SMI or ID/DD to compare effectiveness and implementation of "Tailored Best Practices" (TBP) consisting of evidence-based COVID-19 infection prevention practices adapted for residents with SMI and ID/DD and GH staff; to "General Best Practices" (GBP), consisting of required standard of care reflecting state and federal standard general guidelines for COVID-19 prevention in GHs. External (i.e., community-based research staff) and internal (i.e., GH staff leadership) personnel will facilitate implementation of TBP. The primary effectiveness outcome is incident SARS-CoV-2 infection and secondary effectiveness outcomes include COVID-19-related hospitalizations and mortality in GHs. The primary implementation outcomes are fidelity to TBP and rates of COVID-19 vaccination. Secondary implementation outcomes are adoption, adaptation, reach, and maintenance. Outcomes will be assessed at baseline, 3-, 6-, 9-, 12-, and 15-months post-randomization.

CONCLUSIONS

This study will advance knowledge on comparative effectiveness and implementation of two different strategies to prevent COVID-19-related infection, morbidity, and mortality and promote fidelity and adoption of these interventions in high-risk GHs for residents with SMI or ID/DD and staff.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04726371.

Development of a complex intervention (safe and secure) to support non-western migrant patients with palliative care needs and their families

PURPOSE

International evidence supports the benefits of early use of palliative care, although the best use of services is often under-utilised among Danish migrants. The study aims to develop a theoretically informed, evidence-based intervention to increase support in palliative care service provision among non-western migrant patients with a life-threatening disease and their families in Denmark.

METHODS

The overall approach was guided by the United Kingdom Medical Research Council framework for developing and evaluating complex interventions by involving stakeholders for example patients, family caregivers, and healthcare professionals. The intervention was developed iteratively by incorporating theory and evidence. Evidence was synthesized from a systematic review, semi-structured interviews, and group discussions with patients (n = 8), family caregivers (n = 11), healthcare professionals (n = 10); and three workshops with migrants (n = 5), social and healthcare professionals (n = 6). The study took place in six different settings in two regions across Denmark.

RESULTS

The safe and secure complex intervention is a healthcare professional (e.g. nurse, physiotherapist, or occupational therapist) led patient-centred palliative care intervention at the basic level. The final intervention consists of three components 1. Education and training sessions, 2. Consultations with the healthcare professional, and 3. Coordination of care.

CONCLUSION

This study describes the development of a supportive palliative care intervention for non-western migrant patients with palliative care needs and their families, followed by a transparent and systematic reporting process. A palliative care intervention combining multiple components targeting different stakeholders, is expected that safe and secure is more suitable and well customized in increasing access and use of palliative care services for non-western migrant families in Denmark.

Walking the line between assessment, improvement and learning: a qualitative study on opportunities and risks of incorporating peer discussion of audit and feedback within quality improvement in general practice

OBJECTIVES

There is a broad call for change towards 'new era' quality systems in healthcare, in which the focus lies on learning and improving. A promising way to establish this in general practice care is to combine audit and feedback with peer group discussion. However, it is not known what different stakeholders think of this type of quality improvement. The aim of this research was to explore the opinions of different stakeholders in general practice on peer discussion of audit and feedback and on its opportunities and risks. Second, their thoughts on transparency versus accountability, regarding this system, were studied.

DESIGN

An exploratory qualitative study within a constructivist paradigm. Semistructured interviews and focus group discussions were held and coded using thematic analysis. Included stakeholders were general practitioners (GP), patients, professional organisations and insurance companies.

SETTING

General practice in the Netherlands.

PARTICIPANTS

22 participants were purposively sampled for eight interviews and two focus group discussions.

RESULTS

Three main opportunities of peer discussion of audit and feedback were identified: deeper levels of reflection on data, adding context to numbers and more ownership; and three main risks: handling of unwilling colleagues, lacking a safe group and the necessity of patient involvement. An additional theme concerned disagreement on the amount of transparency to be offered: insurance companies and patients advocated for complete transparency on data and improvement of outcomes, while GPs and professional organisations urged to restrict transparency to giving insight into the process.

CONCLUSIONS

Peer discussion of audit and feedback could be part of a change movement, towards a quality system based on learning and trust, that is initiated by the profession. Creating a safe learning environment and involving patients is key herein. Caution is needed when complete transparency is asked, since it could jeopardise practitioners' reflection and learning in safety.

Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial

BACKGROUND

Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals.

METHODS

A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes.

DISCUSSION

We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas.

TRIAL REGISTRATION

ACTRN12622000028707. Registered 14 January, 2022.

Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review

BACKGROUND

Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies.

METHODS

A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001-2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results.

RESULTS

Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3-17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders' interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8).

CONCLUSION

This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined.

TRIAL REGISTRATION

This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.

'The way that we are collecting and using data has evolved' evaluating the Australian National Stroke Audit programme to inform strategic direction

BACKGROUND

The National Stroke Audit has been used to audit and provide feedback to health professionals and stroke care services in Australia since 2007. The Australian Stroke Clinical Registry was piloted in 2009 and numbers of hospitals participating in the registry are increasing. Considering the changing data landscape in Australia, we designed this study to evaluate the stroke audit and to inform strategic direction.

METHODS

We conducted a rapid review of published literature to map features of successful data programmes, followed by a mixed-methods study, comprising national surveys and interviews with clinicians and administrators about the stroke audit. We analysed quantitative data descriptively and analysed open-ended survey responses and interview data using qualitative content analysis. We integrated data from the two sources.

RESULTS

We identified 47 Australian data programs, successful programs were usually funded by government sources or professional associations and typically provided twice yearly or yearly reports.106 survey participants, 14 clinician and 5 health administrator interview participants were included in the evaluation. The Stroke Audit was consistently perceived as useful for benchmarking, but there were mixed views about its value for local quality improvement. Time to enter data was the most frequently reported barrier to participation (88% of survey participants), due to the large number of datapoints and features of the audit software.Opportunities to improve the Stroke Audit included refining Audit questions, developing ways to automatically export data from electronic medical records and capturing accurate data for patients who transferred between hospitals.

CONCLUSION

While the Stroke Audit was not perceived by all users to be beneficial for traditional quality improvement purposes, the ability to benchmark national stroke services and use these data in advocacy activities was a consistently reported benefit. Modifications were suggested to improve usability and usefulness for participating sites.

Population-Based Analysis of Nonsteroidal Anti-inflammatory Drug Prescription in Subjects With Chronic Kidney Disease

Background

Pain is a prevalent symptom experienced by patients with chronic kidney disease (CKD) and appropriate management of pain is an important element of comprehensive care. Nonsteroidal anti-inflammatory drugs (NSAID) are known to be nephrotoxic in persons with CKD.

Objective

This study examined the pattern of NSAID prescribing practices in a population based-cohort of patients with CKD.

Design

Retrospective cohort study using linked population-based health care data.

Setting

Entire province of Alberta, Canada.

Participants

All adults in Alberta with eGFR defined CKD G3 or greater between 2009 and 2017 were included.

Measurements

CKD was defined using at least 2 outpatient serum creatinine (SCr) greater than 90 days apart; the date of second SCr measurement was used as index date. We determined the incidence of hyperkalemia using the peak serum potassium. Prescription drug information was obtained from the Pharmaceutical Information Network (PIN) database.

Methods

All patients were followed from the index date until March 31, 2019, with a minimum follow-up of 2 years. Prescription drug information and the follow-up laboratory testing of serum creatinine and serum potassium were obtained. Patients with kidney failure defined as eGFR < 15 mL/min per 1.73 m², receiving chronic dialysis, or prior kidney transplant at baseline were excluded.

Results

A total of 170 574 adults (mean age 76.3; 44% male) with CKD were identified and followed for a median of 7 years; 27% were dispensed at least 1 NSAID prescription. While there was a trend toward fewer prescriptions in patients with more advanced CKD (P < .001), 16% of those with CKD G4 were prescribed an NSAID. Primary care providers provided 79% of the prescriptions. Among NSAID users, 21% had a follow-up serum creatinine (SCr) within 30 days of the index prescription.

Limitations

Data collected were from clinical and administrative databases not created for research purposes. The study cohort is limited to subjects who sought medical care and had a serum creatinine measurement obtained. Measurement of NSAID use is limited to those who were dispensed a prescription, over-the-counter NSAIDs use is not captured.

Conclusions

Despite guidelines advocating cautious use of NSAIDs in patients with CKD, this study indicates that there is a discrepancy from best practice recommendations. Effective strategies to better support and educate prescribers, as well as patients, may help reduce inappropriate prescribing and adverse events.

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

OBJECTIVES

Antibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall.

METHODS

Medline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group's tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness.

RESULTS

Nineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers.

CONCLUSIONS

Nudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.

Characterizing the Gaps Between Best-Practice Implementation Strategies and Real-world Implementation: Qualitative Study Among Family Physicians Who Engaged With Audit and Feedback Reports

BACKGROUND

In Ontario, Canada, a government agency known as Ontario Health is responsible for making audit and feedback reports available to all family physicians to encourage ongoing quality improvement. The confidential report provides summary data on 3 key areas of practice: safe prescription, cancer screening, and diabetes management.

OBJECTIVE

This report was redesigned to improve its usability in line with evidence. The objective of this study was to explore how the redesign was perceived, with an emphasis on recipients' understanding of the report and their engagement with it.

METHODS

We conducted qualitative semistructured interviews with family physicians who had experience with both versions of the report recruited through purposeful and snowball sampling. We analyzed the transcripts following an emergent and iterative approach.

RESULTS

Saturation was reached after 17 family physicians participated. In total, 2 key themes emerged as factors that affected the perceived usability of the report: alignment between the report and the recipients' expectations and capacity to engage in quality improvement. Family physicians expected the report and its quality indicators to reflect best practices and to be valid and accurate. They also expected the report to offer feedback on the clinical activities they perceived to be within their control to change. Furthermore, family physicians expected the goal of the report to be aligned with their perspective on feasible quality improvement activities. Most of these expectations were not met, limiting the perceived usability of the report. The capacity to engage with audit and feedback was hindered by several organizational and physician-level barriers, including the lack of fit with the existing workflow, competing priorities, time constraints, and insufficient skills for bridging the gaps between their data and the corresponding desired actions.

CONCLUSIONS

Despite recognized improvements in the design of the report to better align with best practices, it was not perceived as highly usable. Improvements in the presentation of the data could not overcome misalignment with family physicians' expectations or the limited capacity to engage with the report. Integrating iterative evaluations informed by user-centered design can complement evidence-based guidance for implementation strategies. Creating a space for bringing together audit and feedback designers and recipients may help improve usability and effectiveness.

Interventions to improve the implementation of evidence-based healthcare in prisons: a scoping review

BACKGROUND

There are challenges to delivering high quality primary care within prison settings and well-recognised gaps between evidence and practice. There is a growing body of literature evaluating interventions to implement evidence-based practice in the general population, yet the extent and rigour of such evaluations in incarcerated populations are unknown. We therefore conducted a scoping literature review to identify and describe evaluations of implementation interventions in the prison setting.

METHODS

We searched EMBASE, MEDLINE, CINAHL Plus, Scopus, and grey literature up to August 2021, supplemented by hand searching. Search terms included prisons, evidence-based practice, and implementation science with relevant synonyms. Two reviewers independently selected studies for inclusion. Data extraction included study populations, study design, outcomes, and author conclusions. We took a narrative approach to data synthesis. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance for scoping reviews.

RESULTS

Fifteen studies reported in 17 papers comprised one randomised controlled trial, one controlled interrupted time series analysis and 13 uncontrolled before and after studies. Eight studies took place in the US and four in the UK. Ten studies evaluated combined (multifaceted) interventions, typically including education for staff or patients. Interventions most commonly targeted communicable diseases, mental health and screening uptake. Thirteen studies reported adherence to processes of care, mainly testing, prescribing and referrals. Fourteen studies concluded that interventions had positive impacts.

CONCLUSIONS

There is a paucity of high-quality evidence to inform strategies to implement evidence-based health care in prisons, and an over-reliance on weak evaluation designs which may over-estimate effectiveness. Whilst most evaluations have focused on recognised priorities for the incarcerated population, relatively little attention has been paid to long-term conditions core to primary care delivery. Initiatives to close the gaps between evidence and practice in prison primary care need a stronger evidence base.

Performance Feedback for Human Papillomavirus Vaccination: A Randomized Trial From the American Academy of Pediatrics Pediatric Research in Office Settings Research Network

OBJECTIVE

To test the hypothesis that a feedback-based intervention would reduce human papillomavirus (HPV) vaccine missed opportunities.

METHODS

In a longitudinal cluster randomized controlled trial of 48 pediatric primary care practices, we allocated half the practices to receive a sequential, multicomponent intervention phased over consecutive periods. In a prior trial (period 1), communication skills training reduced missed opportunities for the initial HPV vaccine dose at well visits but not at acute/chronic visits. The current trial (period 2) evaluated the added value of performance feedback to clinicians after communication training. Performance feedback consisted of an introductory training module, weekly electronic "Quick Tips," and 3 individualized performance feedback reports to clinicians. We fit logistic regression models for the primary outcome of HPV vaccination missed opportunities using generalized estimating equations with independence working correlation, accounting for clustering at the practice level.

RESULTS

Performance feedback resulted in a 3.4 (95% confidence interval [CI]: -6.8, 0.0) percentage point greater reduction in missed HPV vaccine opportunities for the intervention versus control group during acute/chronic visits for subsequent HPV vaccinations (dose 2 or 3). However, during well visits for HPV vaccination dose #1, intervention practices increased missed opportunities (worsened) by 4.2 (95% CI: 1.0, 7.4) percentage points more than control practices, reducing the prior period 1 improvements and blunting the overall effect of performance feedback. We did not observe differences for the other visit/dose categories.

CONCLUSIONS

Performance feedback improved HPV vaccination for one subset of visits (acute/chronic, subsequent HPV vaccinations due), but not for well visits.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Clinician Perceptions of Receiving Different Forms of Feedback on their Opioid Prescribing

Opioid misuse represents a major public health issue in the United States. One driver is overprescription for acute pain, with the size of initial prescription associated with subsequent long-term use. However, little work has been done to elicit clinician feedback about interventions to reduce opioid prescribing. To address this knowledge gap, qualitative analyses were conducted with clinicians who participated in a randomized controlled trial in which clinicians received monthly emailed feedback notifications about their opioid prescribing behaviors. Semistructured telephone interviews were conducted (N = 12) with urgent care (N = 7) and emergency department (N = 5) clinicians who participated in the trial between November 2020 and April 2021. Clinicians appreciated feedback about their prescribing behavior and found comparative data with peer clinicians to be most useful. Sharing opioid prescribing feedback data with clinicians can be an acceptable way to address opioid prescribing among emergency and urgent care clinicians.

A Systematic Review of Electronic Medical Record Driven Quality Measurement and Feedback Systems

Historically, quality measurement analyses utilize manual chart abstraction from data collected primarily for administrative purposes. These methods are resource-intensive, time-delayed, and often lack clinical relevance. Electronic Medical Records (EMRs) have increased data availability and opportunities for quality measurement. However, little is known about the effectiveness of Measurement Feedback Systems (MFSs) in utilizing EMR data. This study explores the effectiveness and characteristics of EMR-enabled MFSs in tertiary care. The search strategy guided by the PICO Framework was executed in four databases. Two reviewers screened abstracts and manuscripts. Data on effect and intervention characteristics were extracted using a tailored version of the Cochrane EPOC abstraction tool. Due to study heterogeneity, a narrative synthesis was conducted and reported according to PRISMA guidelines. A total of 14 unique MFS studies were extracted and synthesized, of which 12 had positive effects on outcomes. Findings indicate that quality measurement using EMR data is feasible in certain contexts and successful MFSs often incorporated electronic feedback methods, supported by clinical leadership and action planning. EMR-enabled MFSs have the potential to reduce the burden of data collection for quality measurement but further research is needed to evaluate EMR-enabled MFSs to translate and scale findings to broader implementation contexts.

Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine

BACKGROUND

Assessment and feedback is a common implementation strategy to improve healthcare provider fidelity to clinical guidelines. For immunization guidelines, fidelity is often measured with doses administered during eligible visits. Adding a patient refusal measure captures provider fidelity more completely (i.e., all instances of a provider recommending a vaccine, resulting in vaccination or refusal) and enables providers to track patient vaccine hesitancy patterns. However, many electronic health record (EHR) systems have no structured field to document multiple instances of refusals for specific vaccines, and existing billing codes for refusal are not vaccine specific. This study assessed the feasibility of a novel method for refusal documentation used in a study focused on human papillomavirus (HPV) vaccine.

METHODS

An observational, descriptive-comparative, mixed-methods study design was used to conduct secondary data analysis from an implementation-effectiveness trial. The parent trial compared coach-based versus web-based practice facilitation, including assessment and feedback, to increase HPV vaccination in 21 community-based private pediatric practices. Providers were instructed to document initial HPV vaccine refusals in the EHR's immunization forms and subsequent refusals using dummy procedure codes, for use in assessment and feedback reports. This analysis examined adoption and maintenance of the refusal documentation method during eligible well visits, identified barriers and facilitators to documentation and described demographic patterns in patient refusals.

RESULTS

Seven practices adopted the refusal documentation method. Among adopter practices, documented refusals started at 2.4% of eligible well visits at baseline, increased to 14.2% at the start of implementation, peaked at 24.0%, then declined to 18.8%. Barriers to refusal documentation included low prioritization, workflow integration and complication of the billing process. Facilitators included high motivation, documentation instructions and coach support. Among adopter practices, odds of refusing HPV vaccine were 25% higher for patients aged 15-17 years versus 11-12 years, and 18% lower for males versus females.

CONCLUSIONS

We demonstrated the value of patient refusal documentation for measuring HPV vaccination guideline fidelity and ways that it can be improved in future research. Creation of vaccine-specific refusal billing codes or EHR adaptations to enable documenting multiple instances of specific vaccine refusals would facilitate consistent refusal documentation. Trial Registration NCT03399396 Registered in ClinicalTrials.gov on 1/16/2018.

Implementation of an antimicrobial stewardship program in the Australian private hospital system: qualitative study of attitudes to antimicrobial resistance and antimicrobial stewardship

BACKGROUND

Antimicrobial Stewardship (AMS) is a key method to tackle antimicrobial resistance (AMR). In Australia, private hospitals have a higher rate of inappropriate prescribing and non-compliance with antimicrobial guidelines, yet this phenomenon is poorly described. Private hospitals make up 49% of hospitals in Australia, making it vital to understand AMS in this setting.

METHODS

This study aimed to explore capabilities, opportunities and motivations for AMR and AMS with stakeholders at an Australian private hospital, and identify barriers and enablers 5 years post-implementation of an AMS program comparing with pre-implementation findings. A mixed-methods study was performed, involving three focus groups with stakeholders. All doctors, nurses and pharmacists at the hospital were invited to complete a survey on their experiences with and awareness of AMR, AMS and antimicrobial prescribing.

RESULTS

Thirteen staff took part in the focus groups, 100 staff responded to the survey. Staff understood the importance of the AMS program, but active engagement was low. Staff felt more thorough feedback and monitoring could improve prescribing behaviour, but acknowledged difficulty in private hospitals in changing habits of staff who valued autonomy in making prescribing decisions. Half of respondents felt the current AMS restrictions should continue. Executive engagement may be needed to drive system changes across a complex network.

CONCLUSION

AMS awareness increased post-implementation, but staff remained sceptical of its benefits. Engagement and education of medical consultants regarding local benefits of AMS must improve. Enhanced understanding of feedback provision, methods for engagement, and advocacy from leadership will ensure success and longevity for the program.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia

BACKGROUND

The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers.

METHODS

The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127).

RESULTS

Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body.

CONCLUSION

Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments

Background

Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome.

Materials and methods

Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation.

Results

Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only.

Discussion

Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation.

Conclusion

This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

Data-driven development of the nationwide hip fracture registry in the Netherlands

Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators.

PURPOSE

Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA).

METHODS

An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made.

RESULTS

In 4.904 analyzed patients, three tested variables had significant associations (p < 0.01) with outcomes: polypharmacy with complications (aOR 1.34), serum hemoglobin at admittance with complications (aOR 0.63) and mortality (aOR for 30-day mortality 0.78), and a set of questions screening for risk of delirium with complications in general (aOR 1.55), e.g., delirium (aOR 2.98), and decreased functional scores at three months (aOR 1.98).

CONCLUSION

This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.

ANDA-Evaluating Facilitated Feedback Enhancement - a Cluster randomised Trial (ANDA-EFFECT): protocol for a cluster randomised trial of audit feedback augmented with education and support, compared to feedback alone, on acceptability, utility and health outcomes in diabetes centres in Australia

BACKGROUND

People living with diabetes must manage a range of factors for optimal control of glycaemia and to minimise the risk of diabetes-related complications. Diabetes practitioners are expected to follow guidelines for the key process of care and clinical outcomes, to help people living with diabetes achieve clinical targets. In Australia, the performance of diabetes centres against guidelines is evaluated by the Australian National Diabetes Audit, an annual clinical audit and feedback activity. Previous work has identified areas for improvement in the feedback provided to participating diabetes centres and suggested additional educational and support resources to assist in using audit feedback for the development of quality improvement activities. This cluster randomised trial will test the acceptability, utility and impact on selected clinical outcomes of the developed study intervention (audit feedback and a tailored educational and peer support cointervention).

METHODS

Two-armed cluster randomised trial with Australian Diabetes Centres that participated in the Australian National Diabetes Audit in 2021 as the clusters, stratified by location and type of centre. We aim to recruit 35 diabetes centres in each arm. Both the intervention and control arms will receive an augmented feedback report, accompanied by a partially pre-populated slide deck. In addition, the intervention arm will receive a tailored theory-based intervention designed to address identified, modifiable barriers to utilising and implementing the recommendations from diabetes audit feedback. The co-primary outcomes are (1) HbA1c at the patient level, measured at 6 months after delivery of the intervention, and (2) the acceptability and utility of the augmented feedback and cointerventions at the practitioner level, measured at 3 months after delivery of the intervention.

DISCUSSION

This trial aims to test the effects of systematic development and implementation of theory and evidence-informed changes to the audit feedback delivered to diabetes centres participating in an established national clinical diabetes audit. Potential benefits of improved audit feedback include more optimal engagement with the feedback by end clinical users which, ultimately, may lead to improvements in care for people living with diabetes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12621000765820. Prospectively registered on June 21, 2021.

Effects of evidence-based clinical practice guidelines for breast cancer in health care quality improvements. A second systematic review

Background: Traditionally, EB-CPGs have been believed to mainly improve the quality and consistency of health care, but this claim must be conclusively proven. We used the Donabedian three-dimensional model (structure, process, and patient outcomes) to assess improvements in the quality of medical care derived from implementing EB-CPGs. This study corresponds to the second systematic review carried out as a series of studies on different clinical issues that aim to evaluate the effectiveness of the application of the EB-CPG for improving the quality of care. Methods: We followed the methods described by the Cochrane Handbook and presented a descriptive analysis because of the high heterogeneity found across the included studies. We searched the Cochrane Central Register of Controlled Trials, PubMed, and EBSCO Host databases, as well as the grey literature, between 1990 and April 2021. No language restrictions were applied. Only randomised clinical trials (RCTs) were selected. Results: Of the total of 364 interventions included in the eleven RCTs evaluated, 11 (3%) were related to healthcare structure, 51 (14%) to the healthcare delivery process and 302 (83%) to patient outcomes. Regarding the impact of using the EB-CPGs, in 303 interventions (83%), there were no significant differences between the control and experimental groups. In 4 interventions (1%), the result favoured the control and intervention groups in 57 of the interventions (16%). Conclusions: Our study showed that EB-CPGs slightly enhanced the quality of health care in the three dimensions described by Donabedian. Future RCTs should improve their design and methodological rigour by considering the certainty of the evidence supporting the EB-CPGs recommendations. In that context, broader analyses could be performed, having more concise hypotheses for further research. Registration: PROSPERO CRD42020205594.

Baseline assessment of enhanced recovery after pediatric surgery in mainland China

BACKGROUND

Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China.

METHODS

We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD).

RESULTS

A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%).

CONCLUSIONS

The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.

A Stepped-Wedge Cluster-Randomized Trial to Improve Adherence to Evidence-Based Practices for Acute Stroke Management

BACKGROUND

There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data.

METHODS

STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change champions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and individual indicators (secondary outcome). Patient survival and disability 90-180 days after stroke were also compared.

RESULTS

Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years; 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years; 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals' action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05-1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50-2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05-1.53). Patient outcomes were unchanged.

CONCLUSION

External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care.

Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series

BACKGROUND

When a new guideline is published  there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings.

METHODS

Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change.

RESULTS

Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location.

CONCLUSIONS

The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model.

TRIAL REGISTRATION

This study does not report the results of a health care intervention on human participants.

The use of postal audit and feedback among Irish General Practitioners for the self – management of antimicrobial prescribing: a qualitative study

Objective

Inappropriate use of antibiotics has been acknowledged as a significant contributor to the proliferation of antimicrobial resistance worldwide. Physician prescribing of antibiotics has been identified as a factor in the inappropriate use of antibiotics. One methodology that is used in an attempt to alter physician prescribing behaviours is audit and feedback. This study aimed to explore the perceptions of Irish General Practitioners (GPs) towards the national introduction of postal feedback on their antibiotic prescribing behaviours beginning in 2019.

Design

A qualitative descriptive methodology was used. Semi–structured interviews were conducted with GPs in receipt of postal audit and feedback.

Method

GPs working in Ireland and in receipt of postal audit and feedback on their antibiotic prescribing behaviours participated in phone-based interviews. The interviews were recorded and transcribed verbatim. The collected data was then analysed using an inductive thematic analysis.

Results

Twelve GPs participated in the study (female = 5). Three themes were identified from the analysis. The themes identified were the reliability and validity of the feedback received, feedback on antibiotic prescribing is useful but limited and feedback needs to be easily digestible.

Conclusion

While the postal audit and feedback were broadly welcomed by the participants, the themes identified a perceived limitation in the quality of the feedback data, the perception of a likely low public health impact of the feedback and difficulties with efficiently processing the audit and feedback information. These findings can help refine future audit and feedback interventions on antibiotic prescribing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01695-x.

Implementing an audit and feedback cycle to improve adherence to the Choosing Wisely Canada recommendations: clustered randomized trail

BACKGROUND

Audit and Feedback (A&F), a strategy aimed at promoting modified practice through performance feedback, is a method to change provider behaviour and reduce unnecessary medical services. This study aims to assess the use of A&F to reduce antibiotic prescribing for viral infections and antipsychotic prescribing to patients with dementia.

METHODS

Clustered randomized trial of 239 primary care providers in Manitoba, Canada, participating in the Manitoba Primary Care Research Network. Forty-six practices were randomly assigned to one of three groups: control group, intervention 1 (recommendations summary), intervention 2 (recommendations summary and personalized feedback). We assessed prescribing rates prior to the intervention (2014/15), during and immediately after the intervention (2016/17) and following the intervention (2018/19). Physician characteristics were assessed.

RESULTS

Between 2014/15-2016/17, 91.6% of providers in intervention group 1 and 95.9% of providers in intervention group 2 reduced their antibiotic and antipsychotic prescribing rate by ≥ 1 compared to the control group (77.6%) (p-value 0.0073). This reduction was maintained into 2018/19 at 91.4%. On multivariate regression alternatively funded providers had 2.4 × higher odds of reducing their antibiotic prescribing rate compared to fee-for-service providers. In quantile regression of providers with a reduction in antibiotic prescribing, alternatively funded (e.g. salaried or locum) providers compared to fee-for-service providers were significant at the 80th quantile.

CONCLUSIONS

Both A&F and recommendation summaries sent to providers by a trusted source reduced unnecessary prescriptions. Our findings support further scale up of efforts to engage with primary care practices to improve care with A&F.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05385445, retrospectively registered, 23/05/2022.

Educational interventions to improve detection and management of cognitive decline in primary care-An Italian multicenter pragmatic study

Introduction

Timely detection of cognitive decline in primary care is essential to promote an appropriate care pathway and enhance the benefits of interventions. We present the results of a study aimed to evaluate the effectiveness of an educational intervention addressed to Italian family physicians (FPs) to improve timely detection and management of cognitive decline.

Materials and methods

We conducted a pre-post study in six Italian health authorities (HAs) involving 254 FPs and 3,736 patients. We measured process and outcome indicators before the intervention (1 January 2014 to 31 December 2016) and after the intervention (1 January 2018 to 31 December 2019). One interactive face-to-face session workshop was delivered by local cognitive disorders and dementia specialists and FP advisors at each HA, in the period September 2017-December 2017. The session focused on key messages of the local Diagnostic and Therapeutic Care Pathway (DTCP) or regional guidelines: (a) the role of the FP for a timely suspicion of cognitive decline is fundamental; (b) when cognitive decline is suspected, the role of the FP is active in the diagnostic work-up; (c) FP's knowledge on pharmacological and non-pharmacological interventions is essential to improve the management of patients with cognitive decline.

Results

An overall improvement in diagnostic procedures and management of patients with cognitive decline by FPs after the intervention was observed. The number of visits per year performed by FPs increased, and the time interval between the first FP consultation and the diagnosis was optimized. Neuroleptic use significantly decreased, whereas the use of benzodiazepines remained steadily high. Non-pharmacological interventions, or use of support services, were underrepresented even in the post-intervention. Differences among the participating HAs were identified and discussed.

Discussion

Results from this study suggest the success of the educational intervention addressed to FPs in improving early detection and management of cognitive decline, highlighting the importance to continue medical education in this field. At the same time, further initiatives of care pathway dissemination and implementation should promote strategies to enhance interactions between primary and secondary care optimizing the collaboration between FPs and specialists.

Reporting unit context data to stakeholders in long-term care: a practical approach

Background

The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context.

Methods

We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis.

Results

Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method.

Conclusions

We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.

Which strategies support the effective use of clinical practice guidelines and clinical quality registry data to inform health service delivery? A systematic review

BACKGROUND

Empirical evidence suggests data and insights from the clinical practice guidelines and clinical quality registries are not being fully utilised, leaving health service managers, clinicians and providers without clear guidance on how best to improve healthcare delivery. This lack of uptake of existing research knowledge represents low value to the healthcare system and needs to change.

METHODS

Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews) were systematically searched. Included studies were published between 2000 and 2020 reporting on the attributes, evidence usage and impact of clinical practice guidelines and clinical quality registries on health service delivery.

RESULTS

Twenty-six articles including one randomised controlled trial, eight before-and-after studies, eight case studies/reviews, five surveys and four interview studies, covering a wide range of medical conditions and conducted in the USA, Australia and Europe, were identified. Five complementary strategies were derived to maximise the likelihood of best practice health service delivery: (1) feedback and transparency, (2) intervention sustainability, (3) clinical practice guideline adherence, (4) productive partnerships and (5) whole-of-team approach.

CONCLUSION

These five strategies, used in context-relevant combinations, are most likely to support the application of existing high-quality data, adding value to health service delivery. The review highlighted the limitations of study design in opportunistic registry studies that do not produce clear, usable evidence to guide changes to health service implementation practices. Recommendations include exploration of innovative methodologies, improved coordination of national registries and the use of incentives to encourage guideline adherence and wider dissemination of strategies used by successful registries.