Local opinion leaders: effects on professional practice and health care outcomes

An Innovative Framework for Sustainable Development in Healthcare: The Human Rights Assessment

Healthcare providers are investing considerable resources for the development of quality management systems in hospitals. Contrary to these efforts, the number of tools that allow the evaluation of implementation efforts and the results of quality, security and sustainable development is quite limited. The purpose of the study is to develop a reference framework for quality and sustainable development in healthcare, Sanitary-Quality (San-Q) at the micro system level, which is compatible with applicable national and international standards in the field. The research method consisted of the study of literature, identification and analysis of good sustainability practices in healthcare, which allowed identification of the areas of the new San-Q framework: quality, economic, environmental, social, institutional and healthcare. These areas are incorporated into the core topics of social responsibility mentioned by ISO26000. A total of 57 indicators have been defined that make up the new reference framework. The evaluation format of the indicators is innovative through a couple of values: completion degree–significance. In the experimental part of the research, a pilot implementation of the San-Q framework at an emergency hospital was performed, the results recorded in terms of responsibility for human rights being presented. The conclusions of the study reveal the innovative aspects of the framework that facilitate the development of a sustainability strategy promoted through performance indicators, the results obtained after evaluation being useful in establishing a reference level of sustainability but also in developing sustainability policies.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

Background

Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.

Methods

We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).

Discussion

De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.

Trial registration

ClinicalTrials.govNCT05020418

Priority-setting to integrate sexual and reproductive health into universal health coverage: the case of Malaysia

Despite increasing calls to integrate and prioritise sexual and reproductive health (SRH) services in universal health coverage (UHC) processes, several SRH services have remained a low priority in countries’ UHC plans. This study aims to understand the priority-setting process of SRH interventions in the context of UHC, drawing on the Malaysian experience. A realist evaluation framework was adopted to examine the priority-setting process for three SRH tracer interventions: pregnancy, safe delivery and post-natal care; gender-based violence (GBV) services; and abortion-related services. The study used a qualitative multi-method design, including a literature and document review, and 20 in-depth key informant interviews, to explore the context–mechanism–outcome configurations that influenced and explained the priority-setting process. Four key advocacy strategies were identified for the effective prioritisation of SRH services, namely: (1) generating public demand and social support, (2) linking SRH issues with public agendas or international commitments, (3) engaging champions that are internal and external to the public health sector, and (4) reframing SRH issues as public health issues. While these strategies successfully triggered mechanisms, such as mutual understanding and increased buy-in of policymakers to prioritise SRH services, the level and extent of prioritisation was affected by both inner and outer contextual factors, in particular the socio-cultural and political context. Priority-setting is a political decision-making process that reflects societal values and norms. Efforts to integrate SRH services in UHC processes need both to make technical arguments and to find strategies to overcome barriers related to societal values (including certain socio-cultural and religious norms). This is particularly important for sensitive SRH services, like GBV and safe abortion, and for certain populations.

Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women

Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.

Evidence-Based Decision Making 5: Knowledge Translation and the Knowledge to Action Cycle

There is a significant gap between what is known and what is implemented by key stakeholders in practice (the evidence to practice gap). The primary purpose of knowledge translation is to address this gap, bridging evidence to clinical practice. The knowledge to action cycle is one framework for knowledge translation that integrates policy makers throughout the research cycle. The knowledge to action cycle begins with the identification of a problem (usually a gap in care provision). After identification of the problem, knowledge creation is undertaken, depicted at the center of the cycle as a funnel. Knowledge inquiry is at the wide end of the funnel, and moving down the funnel, the primary data is synthesized into knowledge products in the form of educational materials, guidelines, decision aids, or clinical pathways. The remaining components of the knowledge to action cycle refer to the action of applying the knowledge that has been created. This includes adapting knowledge to local context, assessing barriers to knowledge use, selecting, tailoring implementing interventions, monitoring knowledge use, evaluating outcomes, and sustaining knowledge use. Each of these steps is connected by bidirectional arrows and ideally involves health-care decision makers and key stakeholders at each transition.

Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis

Upper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs – popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient–physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers’ clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients’ diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.

Feasibility and usefulness of a leadership intervention to implement evidence-based falls prevention practices in residential care in Canada

Background

Leadership is critical to supporting and facilitating the implementation of evidence-based practices in health care. Yet, little is known about how to develop leadership capacity for this purpose. The aims of this study were to explore the (1) feasibility of delivering a leadership intervention to promote implementation, (2) usefulness of the leadership intervention, and (3) participants’ engagement in leadership to implement evidence-based fall prevention practices in Canadian residential care.

Methods

We conducted a mixed-method before-and-after feasibility study on two units in a Canadian residential care facility. The leadership intervention was based on the Ottawa model of implementation leadership (O-MILe) and consisted of two workshops and two individualized coaching sessions over 3 months to develop leadership capacity for implementing evidence-based fall prevention practices. Participants (n = 10) included both formal (e.g., managers) and informal (e.g., nurses and care aids leaders). Outcome measures were parameters of feasibility (e.g., number of eligible candidates who attended the workshops and coaching sessions) and usefulness of the leadership intervention (e.g., ratings, suggested modifications). We conducted semi-structured interviews guided by the Implementation Leadership Scale (ILS), a validated measure of 12-item in four subcategories (proactive, supportive, knowledgeable, and perseverant), to explore the leadership behaviors that participants used to implement fall prevention practices. We repeated the ILS in a focus group meeting to understand the collective leadership behaviors used by the intervention team. Barriers and facilitators to leading implementation were also explored.

Results

Delivery of the leadership intervention was feasible. All participants (n = 10) attended the workshops and eight participated in at least one coaching session. Workshops and coaching were rated useful (≥ 3 on a 0–4 Likert scale where 4 = highly useful) by 71% and 86% of participants, respectively. Participants rated the O-MILe subcategories of supportive and perseverant leadership highest for individual leadership, whereas supportive and knowledgeable leadership were rated highest for team leadership.

Conclusions

The leadership intervention was feasible to deliver, deemed useful by participants, and fostered engagement in implementation leadership activities. Study findings highlight the complexity of developing implementation leadership and modifications required to optimize impact. Future trials are now required to test the effectiveness of the leadership intervention on developing leadership for implementing evidence-based practices.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Modeling the Decision of Mental Health Providers to Implement Evidence-Based Children's Mental Health Services: A Discrete Choice Conjoint Experiment

Using an online, cross sectional discrete choice experiment, we modeled the influence of 14 implementation attributes on the intention of 563 providers to adopt hypothetical evidence-based children’s mental health practices (EBPs). Latent class analysis identified two segments. Segment 1 (12%) would complete 100% of initial training online, devote more time to training, make greater changes to their practices, and introduce only minor modifications to EBPs. Segment 2 (88%) preferred fewer changes, more modifications, less training, but more follow-up. Simulations suggest that enhanced supervisor support would increase the percentage of participants choosing the intensive training required to implement EBPs. The dissemination of EBPs needs to consider the views of segments of service providers with differing preferences regarding EBPs and implementation process design.

Family physicians' experience and understanding of evidence-based practice and guideline implementation in primary care practice, Cape Town, South Africa

BACKGROUND

In primary care, patients present with multimorbidity and a wide spectrum of undifferentiated illnesses, which makes the application of evidence-based practice (EBP) principles more challenging than in other practice contexts.

AIM

The goal of this study was to explore the experiences and understanding of family physicians (FP) in primary care with regard to EBP and the implementation of evidence-based guidelines.

SETTING

The study was conducted in Cape Town primary care facilities and South African university departments of Family Medicine.

METHODS

For this phenomenological, qualitative study, 27 purposefully selected FPs from three groups were interviewed: senior academic FPs; local FPs in public-sector practice; and local FPs in private-sector practice. Data were analysed using the framework method with the assistance of ATLAS.ti, version 6.1.

RESULTS

Guideline development should be a more inclusive process that incorporates more evidence from primary care. Contextualisation should happen at an organisational level and may include adaptation as well as the development of practical or integrated tools. Organisations should ensure synergy between corporate and clinical governance activities. Dissemination should ensure that all practitioners are aware of and know how to access guidelines. Implementation should include training that is interactive and recognises individual practitioners' readiness to change, as well as local barriers. Quality improvement cycles may reinforce implementation and provide feedback on the process.

CONCLUSION

Evidence-based practice is currently limited in its capacity to inform primary care. The conceptual framework provided illustrates the key steps in guideline development, contextualisation, dissemination, implementation and evaluation, as well as the interconnections between steps and barriers or enablers to progress. The framework may be useful for policymakers, health care managers and practitioners in similar settings.

Experiences With the Levonorgestrel Intrauterine System Among Clients, Providers, and Key Opinion Leaders: A Mixed-Methods Study in Nigeria

Between September 2016 and December 2017, Marie Stopes International Organisation Nigeria introduced the LNG IUS in 16 Nigerian states to increase method choice. Just under 1,000 devices were inserted, representing less than 1% of all long-acting reversible contraceptives provided. Qualitative feedback from opinion leaders, providers, and LNG IUS users found important benefits to users and suggested coordinated demand- and supply-side activities, including user champions and supportive providers to generate interest in the method, would be needed for successful scale-up.

Background:

The levonorgestrel intrauterine system (LNG IUS) is one of the most effective contraceptive methods, and it has noncontraceptive health benefits, including treatment for women with heavy menstrual bleeding. In 2016, Marie Stopes International Organisation Nigeria (MSION) expanded LNG IUS provision through training and support to 9 mobile outreach teams, 105 social franchise clinics, and 20 public-sector providers in 17 states. Information about the LNG IUS was added to awareness-raising materials, and community mobilizers provided information on the LNG IUS alongside other voluntary family planning methods.

Methods:

In 2016, Marie Stopes International, MSION, and FHI 360 examined clients' and providers' experiences with the LNG IUS to assess the potential for further scale-up of the method as part of a comprehensive approach to family planning in Nigeria. A mixed-methods approach was used including analysis of routine service data, supplemental data specific to LNG IUS clients, and in-depth interviews with LNG IUS clients, providers, and key opinion leaders.

Results:

Just under 1,000 LNG IUS were inserted from September 2016 to December 2017 in 16 states in channels supported by MSION, representing 0.4% of all long-acting and reversible contraceptive (LARC) services provided by the participating providers during this time frame. The vast majority (82%) of LARCs provided were implants. A small pool of providers was responsible for providing almost half of the LNG IUS services. Common reasons for women choosing the LNG IUS were reduced menstrual bleeding (61%), long-acting duration (52%), effectiveness (49%), and discreetness (42%). Almost 80% of the users first heard about the method from a provider. Almost all users and providers reported positive experiences with the method, noting the noncontraceptive benefits and fewer side effects compared with other methods. All providers who were interviewed said they would continue offering the LNG IUS. Several key opinion leaders mentioned a total market approach incorporating both public and private sectors would be needed to successfully scale up the LNG IUS.

Conclusion:

Reduced menstrual bleeding and fewer side effects compared with other methods were identified as important attributes of the LNG IUS by clients, providers, and key opinion leaders. Challenges to uptake of the LNG IUS include difficulty with introducing a new method within a busy service delivery infrastructure and limited awareness and demand-generation activities on the LNG IUS specifically. A comprehensive product introduction approach with coordinated demand- and supply-side activities may be required for this method to reach its full potential.

Promoting the use of self-management in novice chiropractors treating individuals with spine pain: the design of a theory-based knowledge translation intervention

Background

Clinical practice guidelines generally recommend clinicians use self-management support (SMS) when managing patients with spine pain. However, even within the educational setting, the implementation of SMS remains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for change toward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective of directors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice (EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identify potential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT) intervention to increase the use of SMS.

Methods

Mixed method design. We administered three self-administered questionnaires to assess clinicians’ and interns’ attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, we conducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to explore their beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by 2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identified informing the design of a KT intervention.

Results

Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBP use. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDF domains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention & decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KT intervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning, clinical vignettes, training workshop, and opinion leader support.

Conclusion

SMS strategies can help maximizing the health care services for patients with spine pain. This may in turn optimize patients’ health. The proposed theory-based KT intervention may facilitate the implementation of SMS among clinicians and interns.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2241-1) contains supplementary material, which is available to authorized users.

Keys to success of a community of clinical practice in primary care: a qualitative evaluation of the ECOPIH project

Background

The current reality of primary care (PC) makes it essential to have telemedicine systems available to facilitate communication between care levels. Communities of practice have great potential in terms of care and education, and that is why the Online Communication Tool between Primary and Hospital Care was created. This tool enables PC and non-GP specialist care (SC) professionals to raise clinical cases for consultation and to share information. The objective of this article is to explore healthcare professionals’ views on communities of clinical practice (CoCPs) and the changes that need to be made in an uncontrolled real-life setting after more than two years of use.

Methods

A descriptive-interpretative qualitative study was conducted on a total of 29 healthcare professionals who were users and non-users of a CoCP using 2 focus groups, 3 triangular groups and 5 individual interviews. There were 18 women, 21 physicians and 8 nurses. Of the interviewees, 21 were PC professionals, 24 were users of a CoCP and 7 held managerial positions.

Results

For a system of communication between PC and SC to become a tool that is habitually used and very useful, the interviewees considered that it would have to be able to find quick, effective solutions to the queries raised, based on up-to-date information that is directly applicable to daily clinical practice. Contact should be virtual – and probably collaborative – via a platform integrated into their habitual workstations and led by PC professionals. Organisational changes should be implemented to enable users to have more time in their working day to spend on the tool, and professionals should have a proactive attitude in order to make the most if its potential. It is also important to make certain technological changes, basically aimed at improving the tool’s accessibility, by integrating it into habitual clinical workstations.

Conclusions

The collaborative tool that provides reliable, up-to-date information that is highly transferrable to clinical practice is valued for its effectiveness, efficiency and educational capacity. In order to make the most of its potential in terms of care and education, organisational changes and techniques are required to foster greater use.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0739-0) contains supplementary material, which is available to authorized users.

Adapting the Consolidated Framework for Implementation Research to Create Organizational Readiness and Implementation Tools for Project ECHO

The Project Extension for Community Healthcare Outcomes (ECHO) model expands primary care provider (PCP) capacity to manage complex diseases by sharing knowledge, disseminating best practices, and building a community of practice. The model has expanded rapidly, with over 140 ECHO projects currently established globally. We have used validated implementation frameworks, such as Damschroder's (2009) Consolidated Framework for Implementation Research (CFIR) and Proctor's (2011) taxonomy of implementation outcomes, combined with implementation experience to (1) create a set of questions to assess organizational readiness and suitability of the ECHO model and (2) provide those who have determined ECHO is the correct model with a checklist to support successful implementation. A set of considerations was created, which adapted and consolidated CFIR constructs to create ECHO-specific organizational readiness questions, as well as a process guide for implementation. Each consideration was mapped onto Proctor's (2011) implementation outcomes, and questions relating to the constructs were developed and reviewed for clarity. The Preimplementation list included 20 questions; most questions fall within Proctor's (2001) implementation outcome domains of "Appropriateness" and "Acceptability." The Process Checklist is a 26-item checklist to help launch an ECHO project; items map onto the constructs of Planning, Engaging, Executing, Reflecting, and Evaluating. Given that fidelity to the ECHO model is associated with robust outcomes, effective implementation is critical. These tools will enable programs to work through key considerations to implement a successful Project ECHO. Next steps will include validation with a diverse sample of ECHO projects.

Midwife or doctor local opinion leader to implement a national guideline in babies on postnatal wards (DesIGN): protocol of a cluster-randomised, blinded, controlled trial

INTRODUCTION

Neonatal hypoglycaemia is a common condition that can cause developmental delay. Treatment of neonatal hypoglycaemia with oral dextrose gel has been shown to reverse hypoglycaemia and reduce admissions to neonatal intensive care for hypoglycaemia. An evidence-based clinical practice guideline was written to guide the use of dextrose gel to treat neonatal hypoglycaemia in New Zealand. However, it is unclear what clinical discipline might most effectively lead the implementation of the guideline recommendations.

OBJECTIVE

To determine if midwife or doctor local opinion leaders are more effective in implementing a clinical practice guideline for use of oral dextrose gel to treat hypoglycaemia in babies on postnatal wards.

METHODS AND ANALYSIS

A cluster-randomised, blinded, controlled trial. New Zealand maternity hospitals that care for babies born at risk of neonatal hypoglycaemia will be randomised to having either a local midwife or doctor lead the guideline implementation at that hospital. The primary outcome will be the change in the proportion of hypoglycaemic babies treated with dextrose gel from before implementation of the guideline to 3 months after implementation.

ETHICS AND DISSEMINATION

Approved by Health and Disability Ethics Committee: 15/NTA/31. Findings will be disseminated to peer-reviewed journals, guideline developers and the public.

TRIAL REGISTRATION NUMBER

ISRCTN61154098.

How Health Care Professionals Use Social Media to Create Virtual Communities: An Integrative Review

Background

Prevailing health care structures and cultures restrict intraprofessional communication, inhibiting knowledge dissemination and impacting the translation of research into practice. Virtual communities may facilitate professional networking and knowledge sharing in and between health care disciplines.

Objectives

This study aimed to review the literature on the use of social media by health care professionals in developing virtual communities that facilitate professional networking, knowledge sharing, and evidence-informed practice.

Methods

An integrative literature review was conducted to identify research published between 1990 and 2015. Search strategies sourced electronic databases (PubMed, CINAHL), snowball references, and tables of contents of 3 journals. Papers that evaluated social media use by health care professionals (unless within an education framework) using any research design (except for research protocols or narrative reviews) were included. Standardized data extraction and quality assessment tools were used.

Results

Overall, 72 studies were included: 44 qualitative (including 2 ethnographies, 26 qualitative descriptive, and 1 Q-sort) and 20 mixed-methods studies, and 8 literature reviews. The most common methods of data collection were Web-based observation (n=39), surveys (n=23), interviews (n=11), focus groups (n=2), and diaries (n=1). Study quality was mixed. Social media studied included Listservs (n=22), Twitter (n=18), general social media (n=17), discussion forums (n=7), Web 2.0 (n=3), virtual community of practice (n=3), wiki (n=1), and Facebook (n=1). A range of health care professionals were sampled in the studies, including physicians (n=24), nurses (n=15), allied health professionals (n=14), followed by health care professionals in general (n=8), a multidisciplinary clinical specialty area (n=9), and midwives (n=2). Of 36 virtual communities, 31 were monodiscipline for a discrete clinical specialty. Population uptake by the target group ranged from 1.6% to 29% (n=4). Evaluation using related theories of “planned behavior” and the “technology acceptance model” (n=3) suggests that social media use is mediated by an individual’s positive attitude toward and accessibility of the media, which is reinforced by credible peers. The most common reason to establish a virtual community was to create a forum where relevant specialty knowledge could be shared and professional issues discussed (n=17). Most members demonstrated low posting behaviors but more frequent reading or accessing behaviors. The most common Web-based activity was request for and supply of specialty-specific clinical information. This knowledge sharing is facilitated by a Web-based culture of collectivism, reciprocity, and a respectful noncompetitive environment. Findings suggest that health care professionals view virtual communities as valuable knowledge portals for sourcing clinically relevant and quality information that enables them to make more informed practice decisions.

Conclusions

There is emerging evidence that health care professionals use social media to develop virtual communities to share domain knowledge. These virtual communities, however, currently reflect tribal behaviors of clinicians that may continue to limit knowledge sharing. Further research is required to evaluate the effects of social media on knowledge distribution in clinical practice and importantly whether patient outcomes are significantly improved.

Surveying the Knowledge and Practices of Health Professionals in China, India, Iran, and Mexico on Treating Tuberculosis

Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices "often or very often" (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting systematic reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful.

Presence of a Physician Safety Champion Is Associated with a Reduction in Urinary Catheter Utilization in the Pediatric Intensive Care Unit

Background

Safety champions are effective in a variety of safety initiatives; however, there are no reports of their role in hospital-acquired infections prevention.

Objective

We aimed to describe the association of the presence of a physician safety champion with our urinary catheter device utilization ratios (DUR) in the Pediatric Intensive Care Unit (PICU).

Methods

Our PICU has incidence rates of catheter-associated urinary tract infections (CAUTI) and urinary catheter DUR above the 90^th percentile. Using a quasi-experimental design, we compared our DUR when the PICU team was exposed and unexposed (champion’s maternity leaves) to a physician safety champion. Hospital acquired infection (HAI) surveillance of all PICU admissions between April 1^st 2009 and June 29^th 2013 was done prospectively. To ensure stable acuity of the patient population over time, we used the central venous catheter (CVC) DUR as a control.

Results

The urinary catheter DUR was 0.44 (95% confidence interval [CI] 0.42–0.45) during the unexposed period versus 0.39 (95%CI 0.38–0.40) during the exposed period, for an absolute difference of 0.05 (95%CI 0.03–0.06; p<0.0001). The overall CVC DUR increased from 0.57 (95%CI 0.55–0.58) during the unexposed period to 0.63 (95%CI 0.61–0.64) during the exposed period, an absolute increase of 0.06 (95%CI 0.04–0.08; p<0.0001). Comparing the exposed and unexposed periods, adjusting for time trend, we observed a 17% decrease in the urinary catheter DUR when the safety champion was present (odds ratio [OR] 0.83; 95%CI 0.77–0.90). The rate of catheter-associated urinary tract infections did not change.

Conclusions

The presence of a unit-based safety champion can have a positive impact on urinary catheter DUR in a PICU.

Models of care for musculoskeletal health: a cross-sectional qualitative study of Australian stakeholders' perspectives on relevance and standardised evaluation

BACKGROUND

The prevalence and impact of musculoskeletal conditions are predicted to rapidly escalate in the coming decades. Effective strategies are required to minimise 'evidence-practice', 'burden-policy' and 'burden-service' gaps and optimise health system responsiveness for sustainable, best-practice healthcare. One mechanism by which evidence can be translated into practice and policy is through Models of Care (MoCs), which provide a blueprint for health services planning and delivery. While evidence supports the effectiveness of musculoskeletal MoCs for improving health outcomes and system efficiencies, no standardised national approach to evaluation in terms of their 'readiness' for implementation and 'success' after implementation, is yet available. Further, the value assigned to MoCs by end users is uncertain. This qualitative study aimed to explore end users' views on the relevance of musculoskeletal MoCs to their work and value of a standardised evaluation approach.

METHODS

A cross-sectional qualitative study was undertaken. Subject matter experts (SMEs) with health, policy and administration and consumer backgrounds were drawn from three Australian states. A semi-structured interview schedule was developed and piloted to explore perceptions about musculoskeletal MoCs including: i) aspects important to their work (or life, for consumers) ii) usefulness of standardised evaluation frameworks to judge 'readiness' and 'success' and iii) challenges associated with standardised evaluation. Verbatim transcripts were analysed by two researchers using a grounded theory approach to derive key themes.

RESULTS

Twenty-seven SMEs (n = 19; 70.4 % female) including five (18.5 %) consumers participated in the study. MoCs were perceived as critical for influencing and initiating changes to best-practice healthcare planning and delivery and providing practical guidance on how to implement and evaluate services. A 'readiness' evaluation framework assessing whether critical components across the health system had been considered prior to implementation was strongly supported, while 'success' was perceived as an already familiar evaluation concept. Perceived challenges associated with standardised evaluation included identifying, defining and measuring key 'readiness' and 'success' indicators; impacts of systems and context changes; cost; meaningful stakeholder consultation and developing a widely applicable framework.

CONCLUSIONS

A standardised evaluation framework that includes a strong focus on 'readiness' is important to ensure successful and sustainable implementation of musculoskeletal MoCs.

Supporting chronic pain management across provincial and territorial health systems in Canada: Findings from two stakeholder dialogues

Chronic pain is a serious health problem affecting one in five Canadians. To provide better care for patients affected by chronic pain, there is a need to identify how provinces and territories across the country can strengthen its management. In this report, the authors summarize key findings from two stakeholder dialogues that addressed the support of chronic pain management by health system decisionmakers and across health systems. An overview of examples of the progress that has been made since the dialogues is also provided.

BACKGROUND:

Chronic pain is a serious health problem given its prevalence, associated disability, impact on quality of life and the costs associated with the extensive use of health care services by individuals living with it.

OBJECTIVE:

To summarize the research evidence and elicit health system policymakers’, stakeholders’ and researchers’ tacit knowledge and views about improving chronic pain management in Canada and engaging provincial and territorial health system decision makers in supporting comprehensive chronic pain management in Canada.

METHODS:

For these two topics, the global and local research evidence regarding each of the two problems were synthesized in evidence briefs. Three options were generated for addressing each problem, and implementation considerations were assessed. A stakeholder dialogue regarding each topic was convened (with 29 participants in total) and the deliberations were synthesized.

RESULTS:

To inform the first stakeholder dialogue, the authors found that systematic reviews supported the use of evidence-based tools for strengthening chronic pain management, including patient education, self-management supports, interventions to implement guidelines and multidisciplinary approaches to pain management. While research evidence about patient registries/treatment-monitoring systems is limited, many dialogue participants argued that a registry/system is needed. Many saw a registry as a precondition for moving forward with other options, including creating a national network of chronic pain centres with a coordinating ‘hub’ to provide chronic pain-related decision support and a cross-payer, cross-discipline model of patient-centred primary health care-based chronic pain management. For the second dialogue, systematic reviews indicated that traditional media can be used to positively influence individual health-related behaviours, and that multistakeholder partnerships can contribute to increasing attention devoted to issues on policy agendas. Dialogue participants emphasized the need to mobilize behind an effort to build a national network that would bring together existing organizations and committed individuals.

CONCLUSIONS:

Developing a national network and, thereafter, a national pain strategy are important initiatives that garnered broad-based support during the dialogues. Efforts toward achieving this goal have been made since convening the dialogues.

Application of the principles of evidence-based practice in decision making among senior management in Nova Scotia's addiction services agencies

BACKGROUND

Competency profiles for occupational clusters within Canada's substance abuse workforce (SAW) define the need for skill and knowledge in evidence-based practice (EBP) across all its members. Members of the Senior Management occupational cluster hold ultimate responsibility for decisions made within addiction services agencies and therefore must possess the highest level of proficiency in EBP. The objective of this study was to assess the knowledge of the principles of EBP, and use of the components of the evidence-based decision making (EBDM) process in members of this occupational cluster from selected addiction services agencies in Nova Scotia.

METHODS

A convenience sampling method was used to recruit participants from addiction services agencies. Semi-structured qualitative interviews were conducted with eighteen Senior Management. The interviews were audio-recorded, transcribed verbatim and checked by the participants. Interview transcripts were coded and analyzed for themes using content analysis and assisted by qualitative data analysis software (NVivo 9.0).

RESULTS

Data analysis revealed four main themes: 1) Senior Management believe that addictions services agencies are evidence-based; 2) Consensus-based decision making is the norm; 3) Senior Management understand the principles of EBP and; 4) Senior Management do not themselves use all components of the EBDM process when making decisions, oftentimes delegating components of this process to decision support staff.

CONCLUSIONS

Senior Management possess an understanding of the principles of EBP, however, when making decisions they often delegate components of the EBDM process to decision support staff. Decision support staff are not defined as an occupational cluster in Canada's SAW and have not been ascribed a competency profile. As such, there is no guarantee that this group possesses competency in EBDM. There is a need to advocate for the development of a defined occupational cluster and associated competency profile for this critical group.

Managerial leadership for research use in nursing and allied health care professions: a narrative synthesis protocol

BACKGROUND

Nurses and allied health care professionals (physiotherapists, occupational therapists, speech and language pathologists, dietitians) form more than half of the clinical health care workforce and play a central role in health service delivery. There is a potential to improve the quality of health care if these professionals routinely use research evidence to guide their clinical practice. However, the use of research evidence remains unpredictable and inconsistent. Leadership is consistently described in implementation research as critical to enhancing research use by health care professionals. However, this important literature has not yet been synthesized and there is a lack of clarity on what constitutes effective leadership for research use, or what kinds of intervention effectively develop leadership for the purpose of enabling and enhancing research use in clinical practice. We propose to synthesize the evidence on leadership behaviours amongst front line and senior managers that are associated with research evidence by nurses and allied health care professionals, and then determine the effectiveness of interventions that promote these behaviours.

METHODS/DESIGN

Using an integrated knowledge translation approach that supports a partnership between researchers and knowledge users throughout the research process, we will follow principles of knowledge synthesis using a systematic method to synthesize different types of evidence involving: searching the literature, study selection, data extraction and quality assessment, and analysis. A narrative synthesis will be conducted to explore relationships within and across studies and meta-analysis will be performed if sufficient homogeneity exists across studies employing experimental randomized control trial designs.

DISCUSSION

With the engagement of knowledge users in leadership and practice, we will synthesize the research from a broad range of disciplines to understand the key elements of leadership that supports and enables research use by health care practitioners, and how to develop leadership for the purpose of enhancing research use in clinical practice.

TRIAL REGISTRATION

PROSPERO CRD42014007660.

Impact of IT-enabled intervention on MRI use for back pain

BACKGROUND

The purpose of this study was to examine the impact of a multifaceted, clinical decision support (CDS)-enabled intervention on magnetic resonance imaging (MRI) use in adult primary care patients with low back pain.

METHODS

After a baseline observation period, we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry, as well as 2 accountability tools: mandatory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers. Our primary outcome measure was rate of lumbar-spine MRI use. Secondary measures included utilization of MRI of any body part, comparing it with that of a concurrent national comparison, as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence-based guideline. Chi-squared, t-tests, and logistic regression were used to assess pre- and postintervention differences.

RESULTS

In the study cohort preintervention, 5.3% of low back pain-related primary care visits resulted in lumbar-spine MRI, compared with 3.7% of visits postintervention (P <.0001, adjusted odds ratio 0.68). There was a 30.8% relative decrease (6.5% vs 4.5%, P <.0001, adjusted odds ratio 0.67) in the use of MRI of any body part by the primary care providers in the study cohort. This difference was not detected in the control cohort (5.6% vs 5.3%, P = .712). In the study cohort, adherence to evidence-based guideline in the use of lumbar-spine MRI increased from 78% to 96% (P = .0002).

CONCLUSIONS

CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain.

Effectiveness of a multi-component intervention to reduce delirium incidence in elderly care wards

OBJECTIVE

to examine the effect of a multi-component, delirium prevention intervention on rates of incident delirium for patients admitted to specialist elderly care wards.

DESIGN

'before' and 'after' study.

SETTING

three specialist elderly care wards in a general hospital.

SUBJECTS

older people admitted as emergencies.

METHODS

a multi-component delirium prevention intervention that targeted delirium risk factors was implemented by clinical staff. Demographic information and assessments for delirium risk factors were recorded by research staff within 24 h of admission to the ward. New onset (incident) delirium was diagnosed by daily research staff assessments using the Confusion Assessment Method and Delirium Rating Scale-Revised-98.

RESULTS

a total of 436 patients were recruited (249 in the 'before' and 187 in the 'after' group). Incident delirium was significantly reduced ('before' = 13.3%; 'after' = 4.6%; P = 0.006). Delirium severity and duration were significantly reduced in the 'after' group. Mortality, length of stay, activities of daily living score at discharge and new discharge to residential or nursing home rates were similar for both groups.

CONCLUSIONS

a multi-component, delirium prevention intervention directed at delirium risk factors and implemented by local clinical staff can reduce incident delirium on specialist elderly care wards.

Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings

Delirium occurs in more than half of hospitalized older adults with dementia, substantially worsening outcomes. The use of multiple strategies and a local opinion leader, unit champion, has cumulative and lasting effects compared with single-strategy interventions. The purpose of this article is to describe the early barriers and facilitators to rounding with unit champions in a cluster randomized clinical trial in Year 2 of a 5-year trial (5R01NR011042-02). This is a mixed-method study nested within an ongoing multisite cluster-randomized, controlled clinical trial. Descriptive and comparative statistics were collected on N = 192 nursing rounds. Qualitative data were thematically analyzed. On average, rounds lasted 25.54 min (SD = 13.18) and were conducted with the unit champion 64% of the time. This is one of the first studies to systematically address quantitative and qualitative barriers and facilitators to nurse-led delirium rounds, demonstrating the gradual adoption of an intervention in diverse clinical settings.

A social network analysis on clinical education of diabetic foot

INTRODUCTION

Identification of Educational Influentials (EIs) in clinical settings helps considerably to knowledge transfer among health and medical practice providers. The aim of this study was identifying EIs in diabetic foot ulcers (DFU) by medical students (clerks, interns and residents) and providing their relational pattern in this subject.

METHODS

Subjects were medical students at clerk, intern and resident levels in a local educational hospital. A standard questionnaire with four domains (knowledge, communication, participation and professional ethics) was used for identifying EIs. Students introduced those people with these characteristics who referred them for DFU. Respective communication networks were drawn as intra-group (such as resident-resident) and inter-group (such as intern-resident) networks and quantitative criteria of density, in-degree and out-degree centrality and reciprocity were measured.

RESULTS

The network density of clerks-residents (0.024) and interns-residents (0.038) were higher than clerks-attends (0.015) and interns-attends (0.05); indicating that there were more consulting interactions in former networks than the latter. Degree centrality in residents-related networks (clerks-residents = 2.3; interns-residents = 2.6) were higher than attends-related ones (clerks-attends = 1.1; interns-attends = 1.7), while they were not statistically significant. However, In-degree centralization, which indicating a degree of variance of the whole network of ingoing relationships, in attends-related networks was greater than resident-related networks.

CONCLUSION

Resident were consulted with almost as same as attends on DFU. It showed that residents were playing a remarkable role in knowledge transfer and they can be considered as EIs in this clinical setting. It seemed that the availability was the main reason for this key role.

Improving the quality of care for older adults using evidence-informed clinical care pathways

Background

There has been an intensified focus on quality initiatives within health care. Clinical Networks have been established in Alberta as a structure to improve care within and across settings. One method used by Clinical Networks to improve care is clinical care pathways. The objective of this study was to evaluate an evidence-informed hip fracture acute care pathway before broad implementation.

Methods

The pathway was developed by a provincial Clinical Network and implemented at four of 14 hospitals across the province. Within four months of implementing the pathway, experienced interviewers conducted focus groups with end-users at the four sites. Domains of inquiry focused on indentifying barriers and facilitators to use of the pathway.

Results

Fifteen physicians and 29 other health-care providers participated in eight focus groups. Common themes identified around the pathway order sets included issues with format, workflow and workload, and dissemination. The patient/family educational materials were deemed to be beneficial. Health-care provider education required better support. Overall the pathway was seen to be comprehensive. However, communication about the pathway could have been improved.

Conclusions

This care model is novel in that it combines the concepts of clinical networks, care pathways, and knowledge translation in an effort to provide high-quality, evidence-informed care in a standardized equitable manner across a diverse geographic area.

Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users' engagement in activities

BACKGROUND

This study focuses on people with complex and severe mental health problems who require inpatient rehabilitation. The majority have a diagnosis of schizophrenia whose recovery has been delayed due to non-response to first-line treatments, cognitive impairment, negative symptoms and co-existing problems such as substance misuse. These problems contribute to major impairments in social and everyday functioning necessitating lengthy admissions and high support needs on discharge to the community. Engagement in structured activities reduces negative symptoms of psychosis and may lead to improvement in function, but no trials have been conducted to test the efficacy of interventions that aim to achieve this.

METHODS/DESIGN

This study aims to investigate the clinical and cost-effectiveness of a staff training intervention to increase service users' engagement in activities. This is a single-blind, two-arm cluster randomised controlled trial involving 40 inpatient mental health rehabilitation units across England. Units are randomised on an equal basis to receive either standard care or a "hands-on", manualised staff training programme comprising three distinct phases (predisposing, enabling and reinforcing) delivered by a small team of psychiatrists, occupational therapists, service users and activity workers. The primary outcome is service user engagement in activities 12 months after randomisation, assessed using a standardised measure. Secondary outcomes include social functioning and costs and cost-effectiveness of care.

DISCUSSION

The study will provide much needed evidence for a practical staff training intervention that has potential to improve service user functioning, reducing the need for hospital treatment and supporting successful community discharge. The trial is registered with Current Controlled Trials (Ref ISRCTN25898179).

Factors associated with the provision of hospice care for children

CONTEXT

Children at the end of life often lack access to hospice care at home or in a dedicated facility. The factors that may influence whether or not hospices provide pediatric care are relatively unknown.

OBJECTIVES

The purpose of this study was to understand the institutional and resource factors associated with provision of pediatric hospice care.

METHODS

This study used a retrospective, longitudinal design. The main data source was the 2002 to 2008 California State Hospice Utilization Data Files. The sample size was 311 hospices or 1368 hospice observations over seven years. Drawing on institutional and resource dependence theory, this study used generalized estimating equations to examine the institutional and resource factors associated with provision of pediatric hospice care. Interaction terms were included to assess the moderating effect of resource factors on the relationship between institutional factors and provision of care.

RESULTS

Membership in professional groups increased the probability (19%) of offering hospice services for children. Small- (-22%) and medium-sized (-11%) hospices were less likely to provide care for children. The probability of providing pediatric hospice care diminished (-23%) when competition increased in the prior year. Additionally, small size attenuated the accreditation-provision relationship and medium size magnified the membership-provision relationship.

CONCLUSION

Professional membership may promote conformity to industry standards of pediatric care and remove the unknowns of providing hospice care for children. Hospices, especially medium-sized hospices, interested in developing or expanding care for children may benefit by identifying a pediatric champion to join a professional group.

Diffusion of a collaborative care model in primary care: a longitudinal qualitative study

BACKGROUND

Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process.

METHODS

We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics.

RESULTS

Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs.

CONCLUSION

CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.

Applying a Health Network approach to translate evidence-informed policy into practice: a review and case study on musculoskeletal health

BACKGROUND

While translation of evidence into health policy and practice is recognised as critical to optimising health system performance and health-related outcomes for consumers, mechanisms to effectively achieve these goals are neither well understood, nor widely communicated. Health Networks represent a framework which offers a possible solution to this dilemma, particularly in light of emerging evidence regarding the importance of establishing relationships between stakeholders and identifying clinical leaders to drive evidence integration and translation into policy. This is particularly important for service delivery related to chronic diseases. In Western Australia (WA), disease and population-specific Health Networks are comprised of cross-discipline stakeholders who work collaboratively to develop evidence-informed policies and drive their implementation. Since establishment of the Health Networks in WA, over 50 evidence-informed Models of Care (MoCs) have been produced across 18 condition or population-focused Networks. The aim of this paper is to provide an overview of the Health Network framework in facilitating the translation of evidence into policy and practice with a particular focus on musculoskeletal health.

CASE PRESENTATION

A review of activities of the WA Musculoskeletal Health Network was undertaken, focussing on outcomes and the processes used to achieve them in the context of: development of policy, procurement of funding, stakeholder engagement, publications, and projects undertaken by the Network which aligned to implementation of MoCs.The Musculoskeletal Health Network has developed four MoCs which reflect Australian National Health Priority Areas. Establishment of community-based services for consumers with musculoskeletal health conditions is a key recommendation from these MoCs. Through mapping barriers and enablers to policy implementation, working groups, led by local clinical leaders and supported by the broader Network and government officers, have undertaken a range of integrated projects, such as the establishment of a community-based, multidisciplinary rheumatology service. The success of these projects has been contingent on developing relationships between key stakeholders across the health system.

CONCLUSIONS

In WA, Networks have provided a sustainable mechanism to meaningfully engage consumers, carers, clinicians and other stakeholders; provided a forum to exchange ideas, information and evidence; and collaboratively plan and deliver evidence-based and contextually-appropriate health system improvements for consumers.

Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals

BACKGROUND

A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.

METHODS

A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.

RESULTS

Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%-90% of respondents, but less than 50% stated that these strategies were in place at their institutions.

CONCLUSION

Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preferences for evidence-based practice dissemination in addiction agencies serving women: a discrete-choice conjoint experiment

AIM

  To model variables influencing the dissemination of evidence-based practices to addiction service providers and administrators.

DESIGN

  A discrete-choice conjoint experiment. We systematically varied combinations of 16 dissemination variables that might influence the adoption of evidence-based practices. Participants chose between sets of variables.

SETTING

  Canadian agencies (n = 333) providing addiction services to women.

PARTICIPANTS

  Service providers and administrators (n = 1379).

MEASUREMENTS

  We estimated the relative importance and optimal level of each dissemination variable. We used latent class analysis to identify subsets of participants with different preferences and simulated the conditions under which participants would use more demanding professional development options.

FINDINGS

  Three subsets of participants were identified: outcome-sensitive (52%), process-sensitive (29.6%) and demand-sensitive (18.2%). Across all participants, the number of clients who were expected to benefit from an evidence-based practice exerted the most influence on dissemination choices. If a practice was seen as feasible, co-worker and administrative support influenced decisions. Client benefits were most important to outcome-sensitive participants; type of dissemination process (e.g. active versus passive learning) was more important to process-sensitive participants. Brief options with little follow-up were preferred by demand-sensitive participants. Simulations predicted that initiatives selected and endorsed by government funders would reduce participation.

CONCLUSIONS

  Clinicians and administrators are more likely to adopt evidence-based addiction practices if the practice is seen as helpful to clients, and if it is supported by co-workers and program administration.

The effect of a translating research into practice (TRIP)--cancer intervention on cancer pain management in older adults in hospice

BACKGROUND

Pain is a major concern for individuals with cancer, particularly older adults who make up the largest segment of individuals with cancer and who have some of the most unique pain challenges. One of the priorities of hospice is to provide a pain-free death, and while outcomes are better in hospice, patients still die with poorly controlled pain.

OBJECTIVE

This article reports on the results of a Translating Research into Practice intervention designed to promote the adoption of evidence-based pain practices for older adults with cancer in community-based hospices.

SETTING

  This Institutional Human Subjects Review Board-approved study was a cluster randomized controlled trial implemented in 16 Midwestern hospices.

METHODS

Retrospective medical records from newly admitted patients were used to determine the intervention effect. Additionally, survey and focus group data gathered from hospice staff at the completion of the intervention phase were analyzed.

RESULTS

Improvement on the Cancer Pain Practice Index, an overall composite outcome measure of evidence-based practices for the experimental sites, was not significantly greater than control sites. Decrease in patient pain severity from baseline to post-intervention in the experimental group was greater; however, the result was not statistically significant (P = 0.1032).

CONCLUSIONS

Findings indicate a number of factors that may impact implementation of multicomponent interventions, including unique characteristics and culture of the setting, the level of involvement with the change processes, competing priorities and confounding factors, and complexity of the innovation (practice change). Our results suggest that future study is needed on specific factors to target when implementing a community-based hospice intervention, including determining and measuring intervention fidelity prospectively.

Measurement of a model of implementation for health care: toward a testable theory

Background

Greenhalgh et al. used a considerable evidence-base to develop a comprehensive model of implementation of innovations in healthcare organizations [1]. However, these authors did not fully operationalize their model, making it difficult to test formally. The present paper represents a first step in operationalizing Greenhalgh et al.’s model by providing background, rationale, working definitions, and measurement of key constructs.

Methods

A systematic review of the literature was conducted for key words representing 53 separate sub-constructs from six of the model’s broad constructs. Using an iterative process, we reviewed existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus.

Results

The review and iterative process of team consensus identified three types of data that can been used to operationalize the constructs in the model: survey items, interview questions, and administrative data. Specific examples of each of these are reported.

Conclusion

Despite limitations, the mixed-methods approach to measurement using the survey, interview measure, and administrative data can facilitate research on implementation by providing investigators with a measurement tool that captures most of the constructs identified by the Greenhalgh model. These measures are currently being used to collect data concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs. Testing of psychometric properties and subsequent refinement should enhance the utility of the measures.

Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

Background

There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research.

Methods

The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood?

Results

A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change.

Conclusions

We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process.

Effectiveness of organisational infrastructures to promote evidence-based nursing practice

BACKGROUND

Nurses and midwives form the bulk of the clinical health workforce and play a central role in all health service delivery. There is potential to improve health care quality if nurses routinely use the best available evidence in their clinical practice. Since many of the factors perceived by nurses as barriers to the implementation of evidence-based practice (EBP) lie at the organisational level, it is of interest to devise and assess the effectiveness of organisational infrastructures designed to promote EBP among nurses.

OBJECTIVES

To assess the effectiveness of organisational infrastructures in promoting evidence-based nursing.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, BIREME, IBECS, NHS Economic Evaluations Database, Social Science Citation Index, Science Citation Index and Conference Proceedings Citation Indexes up to 9 March 2011.We developed a new search strategy for this update as the strategy published in 2003 omitted key terms. Additional search methods included: screening reference lists of relevant studies, contacting authors of relevant papers regarding any further published or unpublished work, and searching websites of selected research groups and organisations. 

SELECTION CRITERIA

We considered randomised controlled trials, controlled clinical trials, interrupted times series (ITSs) and controlled before and after studies of an entire or identified component of an organisational infrastructure intervention aimed at promoting EBP in nursing. The participants were all healthcare organisations comprising nurses, midwives and health visitors.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias. For the ITS analysis, we reported the change in the slopes of the regression lines, and the change in the level effect of the outcome at 3, 6, 12 and 24 months follow-up.

MAIN RESULTS

We included one study from the USA (re-analysed as an ITS) involving one hospital and an unknown number of nurses and patients. The study evaluated the effects of a standardised evidence-based nursing procedure on nursing care for patients at risk of developing healthcare-acquired pressure ulcers (HAPUs). If a patient's admission Braden score was below or equal to 18 (i.e. indicating a high risk of developing pressure ulcers), nurses were authorised to initiate a pressure ulcer prevention bundle (i.e. a set of evidence-based clinical interventions) without waiting for a physician order. Re-analysis of data as a time series showed that against a background trend of decreasing HAPU rates, if that trend was assumed to be real, there was no evidence of an intervention effect at three months (mean rate per quarter 0.7%; 95% confidence interval (CI) 1.7 to 3.3; P = 0.457). Given the small percentages post intervention it was not statistically possible to extrapolate effects beyond three months.

AUTHORS' CONCLUSIONS

Despite extensive searching of published and unpublished research we identified only one low-quality study; we excluded many studies due to non-eligible study design. If policy-makers and healthcare organisations wish to promote evidence-based nursing successfully at an organisational level, they must ensure the funding and conduct of well-designed studies to generate evidence to guide policy.

Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281)

BACKGROUND

The IMPaCT Back study (IMplementation to improve Patient Care through Targeted treatment for Back pain) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain (LBP) in primary care. This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aimed at equipping clinicians to deliver it. THE SUBGROUPING AND TARGETED TREATMENT SYSTEM: This system differs from 'one-size fits all' usual practice as it suggests that first contact health care practitioners should systematically allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity. Patients in each subgroup (those at low, medium or high risk of chronicity) are then managed according to a targeted treatment system of increasing complexity. THE SUBGROUPING TOOLS: Subgrouping tools help guide clinical decision-making about treatment and onward referral. Two subgrouping tools have been used in the IMPaCT Back study, a 9-item version used by participating physiotherapists and a 6-item version used by GPs. The targeted treatments. The targeted treatments include a minimal intervention delivered by GPs (for those patients at low risk of poor outcome) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability (for those at medium risk) and additional cognitive-behavioural approaches to help address psychological and social obstacles to recovery (for those at high risk). THE TRAINING PACKAGES: Building on previous interventions for other pilot studies and randomized trials, we have developed and delivered clinical training and support programmes for GPs and physiotherapists.

DISCUSSION

This paper describes in detail the IMPaCT Back study's subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study.

STUDY REGISTRATION

ISRCTN55174281.

Do stakeholders in wound care prefer evidence-based wound care products? A survey in the Netherlands

For several wound products compelling evidence is available on their effectiveness, for example, from systematic reviews. The process of buying, prescribing and applying wound materials involve many stakeholders, who may not be aware of this evidence, although this is essential for uniform and optimum treatment choice. In this survey, we determined the general awareness and use of evidence, based on (Cochrane) systematic reviews, for wound products in open wounds and burns among wound care stakeholders, including doctors, nurses, buyers, pharmacologists and manufacturers. We included 262 stakeholders. Doctors preferred conventional antiseptics (e.g. iodine), while specialised nurses and manufacturers favoured popular products (e.g. silver). Most stakeholders considered silver-containing products as evidence-based effective antiseptics. These were mostly used by specialised nurses (47/57; 82%), although only few of them (9/55; 16%) thought using silver is evidence-based. For burns, silver sulfadiazine and hydrofibre were most popular. The majority of professionals considered using silver sulfadiazine to be evidence-based, which contradicts scientific results. Awareness and use of the Cochrane Library was lower among nurses than among doctors (P < 0.001). Two thirds of the manufacturers were unaware of, or never used, the Cochrane Library. Available compelling evidence in wound care is not equally internalised by stakeholders, which is required to ensure evidence-based decision making.

Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: a study protocol

Background

Canada is among the most prosperous nations in the world, yet the health and wellness outcomes of Canadian children are surprisingly poor. There is some evidence to suggest that these poor health outcomes are partly due to clinical practice variation, which can stem from failure to apply the best available research evidence in clinical practice, otherwise known as knowledge translation (KT). Surprisingly, clinical practice variation, even for common acute paediatric conditions, is pervasive. Clinical practice variation results in unnecessary medical treatments, increased suffering, and increased healthcare costs. This study focuses on improving health outcomes for common paediatric acute health concerns by evaluating strategies that improve KT and reduce clinical practice variation.

Design/Methods

Using a multiple case study design, qualitative and quantitative data will be collected from four emergency departments in western Canada. Data sources will include: pre- and post-implementation focus group data from multidisciplinary healthcare professionals; individual interviews with the local champions, KT intervention providers, and unit/site leaders/managers; Alberta Context Tool (ACT) survey data; and aggregated patient outcome data. Qualitative and quantitative data will be systematically triangulated, and matrices will be built to do cross-case comparison. Explanations will be built about the success or lack of success of the clinical practice guidelines (CPG) and clinical pathways (CPs) uptake based upon the cross-case comparisons.

Significance

This study will generate new knowledge about the potential causal mechanisms and factors which shape implementation. Future studies will track the impact of the CPG/CPs implementation on children's health outcome, and healthcare costs.

The landscape of knowledge translation interventions in cancer control: what do we know and where to next? A review of systematic reviews

Background

Effective implementation strategies are needed to optimize advancements in the fields of cancer diagnosis, treatment, survivorship, and end-of-life care. We conducted a review of systematic reviews to better understand the evidentiary base of implementation strategies in cancer control.

Methods

Using three databases, we conducted a search and identified English-language systematic reviews published between 2005 and 2010 that targeted consumer, professional, organizational, regulatory, or financial interventions, tested exclusively or partially in a cancer context (primary focus); generic or non-cancer-specific reviews were also considered. Data were extracted, appraised, and analyzed by members of the research team, and research ideas to advance the field were proposed.

Results

Thirty-four systematic reviews providing 41 summaries of evidence on 19 unique interventions comprised the evidence base. AMSTAR quality ratings ranged between 2 and 10. Team members rated most of the interventions as promising and in need of further research, and 64 research ideas were identified.

Conclusions

While many interventions show promise of effectiveness in the cancer-control context, few reviews were able to conclude definitively in favor of or against a specific intervention. We discuss the complexity of implementation research and offer suggestions to advance the science in this area.

Assessing healthcare providers' knowledge and practices relating to insecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegal and Tanzania

BACKGROUND

Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain to study evidence/practice gaps given the proven efficacy, cost-effectiveness and disappointing utilization of insecticide-treated nets (ITNs).

METHODS

This study compares what is known about ITNs to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.

RESULTS

The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14).

CONCLUSIONS

Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.

Opinion leaders and changes over time: a survey

Background

Opinion leaders represent one way to disseminate new knowledge and influence the practice behaviors of physicians. This study explored the stability of opinion leaders over time, whether opinion leaders were polymorphic (i.e., influencing multiple practice areas) or monomorphic (i.e., influencing one practice area), and reach of opinion leaders in their local network.

Methods

We surveyed surgeons and pathologists in Ontario to identify opinion leaders for colorectal cancer in 2003 and 2005 and to identify opinion leaders for breast cancer in 2005. We explored whether opinion leaders for colorectal cancer identified in 2003 were re-identified in 2005. We examined whether opinion leaders were considered polymorphic (nominated in 2005 as opinion leaders for both colorectal and breast cancer) or monomorphic (nominated in 2005 for only one condition). Social-network mapping was used to identify the number of local colleagues identifying opinion leaders.

Results

Response rates for surgeons were 41% (2003) and 40% (2005); response rates for pathologists were 42% (2003) and 37% (2005). Four (25%) of the surgical opinion leaders identified in 2003 for colorectal cancer were re-identified in 2005. No pathology opinion leaders for colorectal cancer were identified in both 2003 and 2005. Only 29% of surgical opinion leaders and 17% of pathology opinion leaders identified in the 2005 survey were considered influential for both colorectal cancer and breast cancer. Social-network mapping revealed that only a limited number of general surgeons (12%) or pathologists (7%) were connected to the social networks of identified opinion leaders.

Conclusions

Opinion leaders identified in this study were not stable over a two-year time period and generally appear to be monomorphic, with clearly demarcated areas of expertise and limited spheres of influence. These findings may limit the practicability of routinely using opinion leaders to influence practice.

Adoption of surgical innovations: factors influencing use of sentinel lymph node biopsy for breast cancer

PURPOSE

Sentinel lymph node biopsy (SLNB) has been unevenly adopted into practice in Canada. In this qualitative study, the authors explored individual, institutional, and policy factors that may have influenced SLNB adoption. This information will guide interventions to improve SLNB implementation.

METHODS

Qualitative methodology was used to examine factors influencing SLNB adoption. Grounded theory guided data collection and analysis. Semistructured interviews were based on Roger's diffusion of innovation theory. Purposive and snowball sampling was used to identify participants. Semistructured telephone interviews were conducted with urban, rural, academic, and community health care providers and administrators to ensure all perspectives and motivations were explored. Two individuals independently analyzed data and achieved consensus on emerging themes and their relationship.

RESULTS

A total of 43 interviews were completed with 21 surgeons, 5 pathologists, 7 nuclear medicine physicians, and 10 administrators. Generated themes included awareness of SLNB with the exception of some administrators, acknowledged advantage of SLNB, SLNB compatibility with beliefs regarding axillary staging, acknowledgment that SLNB was a complex innovation to adopt, extensive trialing of SLNB prior to adoption, observable benefits with SLNB, acknowledgment that hospital-level administrative support enabled adoption, desire for a provincial policy supporting SLNB to assist in hospital-level adoption, requirement of a local high-volume breast surgery champion who communicated extensively with team to facilitate local adoption, and need for credentialing of SLNB to ensure quality.

CONCLUSIONS

SLNB is a complex innovation to adopt. Successful adoption was assisted by a high-volume breast cancer surgical champion, interprofessional communication, and administrative support.

Training research: practical recommendations for maximum impact

This review offers practical recommendations regarding research on training in evidence-based practices for mental health and substance abuse treatment. When designing training research, we recommend: (a) aligning with the larger dissemination and implementation literature to consider contextual variables and clearly defining terminology, (b) critically examining the implicit assumptions underlying the stage model of psychotherapy development, (c) incorporating research methods from other disciplines that embrace the principles of formative evaluation and iterative review, and (d) thinking about how technology can be used to take training to scale throughout all stages of a training research project. An example demonstrates the implementation of these recommendations.

Effective implementation of research into practice: an overview of systematic reviews of the health literature

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of interventions has been developed to increase the implementation of research into clinical practice.

FINDINGS

A review of systematic reviews of the effectiveness of interventions designed to increase the use of research in clinical practice. A search for relevant systematic reviews was conducted of Medline and the Cochrane Database of Reviews 1998-2009. 13 systematic reviews containing 313 primary studies were included. Four strategy types are identified: audit and feedback; computerised decision support; opinion leaders; and multifaceted interventions. Nine of the reviews reported on multifaceted interventions. This review highlights the small effects of single interventions such as audit and feedback, computerised decision support and opinion leaders. Systematic reviews of multifaceted interventions claim an improvement in effectiveness over single interventions, with effect sizes ranging from small to moderate. This review found that a number of published systematic reviews fail to state whether the recommended practice change is based on the best available research evidence.

CONCLUSIONS

This overview of systematic reviews updates the body of knowledge relating to the effectiveness of key mechanisms for improving clinical practice and service development. Multifaceted interventions are more likely to improve practice than single interventions such as audit and feedback. This review identified a small literature focusing explicitly on getting research evidence into clinical practice. It emphasizes the importance of ensuring that primary studies and systematic reviews are precise about the extent to which the reported interventions focus on changing practice based on research evidence (as opposed to other information codified in guidelines and education materials).