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

Deploying an asthma dashboard to support quality improvement across a nationally representative sentinel network of 7.6 million people in England

Every year, there are ~100,000 hospital admissions for asthma in the UK, many of which are potentially preventable. Evidence suggests that carefully conceptualised and implemented audit and feedback (A&F) cycles have the potential to improve clinical outcomes for those with chronic conditions. We wanted to investigate the technical feasibility of developing a near-real time asthma dashboard to support A&F interventions for asthma management in primary care. We extracted cross-sectional data on asthma from 756 participating GP practices in the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) database in England comprising 7.6 million registered people. Summary indicators for a GP practice were compared to all participating RCGP RSC practices using practice-level data, for the week 6-12th-Mar-2023. A weekly, automated asthma dashboard with features that can support electronic-A&F cycles that compared key asthma indicators for a GP practice to RCGP RSC could be created ( https://tinyurl.com/3ydtrt85 ): 12-weeks-incidence 0.4% vs 0.4%, annual prevalence 6.1% vs 6.7%, inhaled relievers to preventer 1.2 vs 1.1, self-management plan given 83.4% vs 60.8%, annual reviews 36.8% vs 57.3%, prednisolone prescriptions 2.0% vs 3.2%, influenza vaccination 56.6% vs 55.5%, pneumococcal vaccination ever (aged ≥65 years) 90.2% vs 84.1% and current smokers 14.9% vs 14.8%. Across the RCGP RSC, the rate of hospitalisations was 0.024%; comparative data had to be suppressed for the study practice because of small numbers. We have successfully created an automated near real-time asthma dashboard that can be used to support A&F initiatives to improve asthma care and outcomes in primary care.

Using implementation science to promote the use of the fascia iliaca blocks in hip fracture care

PURPOSE

There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake.

METHODS

We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied.

RESULTS

The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days).

CONCLUSION

Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia

BACKGROUND

Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target.

METHODS

In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card.

RESULTS

Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card.

CONCLUSIONS

A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan.

Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs

BACKGROUND

Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs.

METHODS

Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams.

RESULTS

108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%-60%; p=0.045) and declined for the proxy comparison (61%-42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams.

CONCLUSIONS

Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.

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

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

Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Audit and feedback in cardio- and cerebrovascular setting: Toward a path of high reliability in Italian healthcare

Adopting audit and feedback (A&F) strategies could be a suitable healthcare intervention to fulfill the challenge of monitoring and improving clinical guidelines in evidence-based medicine. Indeed, A&F is used to encourage professionals to better adhere to standard guidelines to improve healthcare performance. Briefly, an audit is an inspection of professional practice in comparison to professional standards or targets whose results are subsequently communicated to professionals in a structured manner. Although A&F strategies have been adopted in several time-dependent settings, such as for acute myocardial infarction (AMI) and stroke, interest of audits in rehabilitation care is also emerging. Recently, the Italian Ministry of Health has funded a national network project called EASY-NET, whose main objective is to evaluate the effectiveness of A&F strategies to improve healthcare practice and equity in various clinical and organizational settings in seven Italian regions. Last but not the least of these regions is the Sicily, represented within the project by the IRCCS Centro Neurolesi Bonino-Pulejo of Messina as the work package 7 (WP7). The EASY-NET WP7 is focused on the effectiveness of A&F strategies in both AMI and ischemic stroke setting, from acute to rehabilitation process of care. In this study, we described the study protocol, including the study design and methodology, providing a detailed description of the new model of A&F based on telemedicine, and discussing the possible challenges of this project.

Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial

BACKGROUND

Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique.

METHODS

Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels.

DISCUSSION

This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05103033 ; 11/2/2021.

Considerations for designing and implementing a surgical peer coaching program: an international survey

BACKGROUND

Surgical peer coaching has been associated with high rates of practice change but remains largely unutilized. The purpose of this study was to survey surgeons internationally to investigate attitudes regarding peer coaching and to identify any international differences to inform the design of future coaching programs.

METHODS

Practicing surgeons in general surgery or related subspecialties were eligible to participate. Invitations to complete the survey were distributed through 13 surgical associations, social media, and personal e-mail invitations. Responses were obtained between June 1st and August 31st, 2020.

RESULTS

A total of 521 surveys were collected. The majority of participants practiced in North America (263; 50%) with remaining respondents from Asia (81; 16%), Europe (34;7%), South America (21; 4%), Africa (17; 3%), and Oceania (6; 1%). Duration of practice was equally distributed across 4 intervals (0-5 years; 6-15 years; 16-25 years; > 25 years). Respondents most frequently identified as general surgeons (290; 67%) and 325 (75%) were male. Awareness of peer coaching was reported by 275 (53%) respondents, with 197 (44%) never seeking formal feedback from peers. The majority of respondents (372; 84%) would be willing to participate in a peer coaching program, with monthly interactions the most desirable frequency reported (193; 51%). Coaching in the operating room was preferred by most participants (360; 86%). Few respondents (67; 14%) would accept coaching from someone unknown to them. Participants identified key coaching program elements as: feedback kept private and confidential (267; 63%); opportunity to provide feedback to the coach (247; 59%); personalized goal setting (244; 58%); and the option to choose one's own coach (205; 49%). The most commonly cited potential barrier to participation was logistical constraints (334; 79%).

CONCLUSION

This international survey of practicing surgeons demonstrated that peer feedback is rarely used in practice, but there is high interest and acceptance of the peer coaching model for continuous professional development. Findings regarding preferred program structure may be useful to inform the design of future peer coaching programs.

Patients Lacking the Capacity to Consent to Hip Fracture Surgery May Be Undergoing Major Operations Without Their Next of Kin Being Involved in Best-Interests Decisions: A Quality Improvement Report

Background Cognitively impaired patients with a hip fracture may be undergoing major operations without attempts being made to involve their next of kin (NoK) in best-interest decisions. Methods We used the Plan-Do-Study-Act (PDSA) methodology to guide our quality improvement (QI) project. Cognitively impaired hip fracture patients were identified retrospectively by searching the hip fracture database of a medium-sized district general hospital (DGH). Their medical notes were reviewed for documented attempts at contacting their NoK prior to surgery as well as on completion of the NoK section of the Consent Form Four. Intervention A simple feedback intervention was delivered in the form of a mixed verbal and visual presentation to the orthopaedic registrars responsible for obtaining consent from these patients. Results Post-intervention, there were documented attempts at contacting the NoK before surgery for all patients, a significant improvement from only 80%. There was also a significant increase in completion of the NoK section of the consent form, from 30% to 64.3%. Conclusions Simple audit and feedback interventions can produce significant positive changes in communication between clinicians and the NoK of cognitively impaired patients with hip fractures. Further interventions have been implemented to sustain these improvements.

Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis

OBJECTIVE

To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents.

DESIGN

Prospective cohort study.

SETTING

The Johns Hopkins Hospital, an urban academic medical center.

PARTICIPANTS

All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program.

INTERVENTION

Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported.

RESULTS

During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001).

CONCLUSIONS AND RELEVANCE

Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.

Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion

Introduction

Avoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention.

Methods

The intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan’s framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor’s outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion.

With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments.

Ethics and dissemination

Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.

Trial registration number

ClinicalTrials.gov Identifier, NCT04324762, registered on 27 March 2020.

Increasing the impact of randomized controlled trials: an example of a hybrid effectiveness-implementation design in psychotherapy research

Randomized controlled trials (RCTs) are the gold standard for clinical research. However, significant delays between completion of RCTs and adoption of evidence-based practices into clinical settings remain. Engagement of stakeholders and implementation-focused outcomes to augment traditional RCTs hold the potential to increase the impact of RCT outcomes for clinical practice and more rapidly lead to the adoption of evidence-based practices in clinical settings. The purpose of this study is to discuss hybrid effectiveness-implementation designs and use a project example to highlight important methodological considerations to enhance the impact of RCTs. A hybrid effectiveness-implementation study assessed the effectiveness and implementation potential of brief cognitive behavioral therapy (bCBT) for rural Veterans. A patient-randomized trial (bCBT vs. enhanced usual care) explored the impact on depression symptoms. Implementation elements included engagement of stakeholders and a multifaceted provider training and support program to increase bCBT use by providers in Veterans Health Administration (VA) community-based outpatient clinics. Implementation outcomes included the number of providers who adopted bCBT, provider fidelity, and delivery outcomes (e.g., use of measurement-based care, treatment engagement, and completion). Hybrid designs offer opportunities to improve the alignment between research and practice, potentially improving dissemination of evidence-based interventions and reducing known delays in the translation from research to practice. Expansion of traditional RCTs through collaborative stakeholder contributions and stakeholder/consumer-informed implementation approaches is critical to improve adoption postproject. Although hybrid designs offer significant benefits related to generalizability and adoption, these approaches involve complex procedures and processes and often come at the cost of reduced internal study controls.

Reducing the Risk of Postoperative Complications After Robot-assisted Radical Prostatectomy in Prostate Cancer Patients: Results of an Audit and Feedback Intervention Following the Implementation of Prospective Data Collection

BACKGROUND

Prospective data collection for perioperative outcomes might increase awareness of surgical results obtained for patients with prostate cancer (PCa) undergoing robot-assisted radical prostatectomy (RARP). This would prompt the implementation of measures aimed at reducing the risk of adverse outcomes.

OBJECTIVE

To assess the efficacy of an audit and feedback process aimed at identifying the most common complications after RARP and at implementing measures to improve outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Overall, 415 patients treated with RARP by a high-volume surgeon were included. Perioperative outcomes for 187 patients treated between September 2016 and December 2017 were prospectively collected at 30 d according to the European Association of Urology guideline recommendations (group 1). An audit and feedback process was implemented in January 2018 whereby the most common complication (anastomotic leak) was identified and measures aimed at improving outcomes (changes in the anastomotic technique) were implemented. The outcomes for group 1 were then compared to 228 patients treated after implementation of the modified surgical technique (group 2).

SURGICAL PROCEDURE

A novel technique for posterior reconstruction and urethrovesical anastomosis was introduced.

MEASUREMENTS

Perioperative outcomes included blood loss, operative time, length of stay, and 30-d postoperative complications. Logistic regression models tested the effect of the novel surgical technique on anastomotic leaks.

RESULTS AND LIMITATIONS

Overall, 97 patients (23%) experienced postoperative complications at 30 d. The rate of anastomotic leaks was significantly lower in group 2 compared to group 1 (3.1% vs 9.6%; p < 0.01). Similarly, overall and Clavien-Dindo grade ≥2 complication rates were lower in group 2 versus group 1 (17% vs 31%, and 6% vs 20%; both p ≤ 0.001). In multivariable analyses, treatment after implementation of changes in the anastomotic technique independently predicted a lower risk of complications (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.38-0.89) and of anastomotic leaks (OR 0.43, 95% CI 0.17-0.97). The lack of randomization represents the main limitation.

CONCLUSIONS

Implementation of changes in the urethrovesical anastomosis technique arising from increased awareness of surgical outcomes reduced the risk of anastomotic leaks. These findings highlight the importance of audit and feedback processes using a standardized method for reporting surgical morbidity.

PATIENT SUMMARY

Increased awareness of surgical outcomes prompted us to change our technique for connecting the bladder to the urethra during robot-assisted surgery to remove the prostate in patients with prostate cancer. These changes resulted in significant improvements in surgical outcomes.

Has the COVID 19 Virus Changed Adherence to Hand Washing among Healthcare Workers?

The aim of the study was to assess adherence to hand washing by healthcare workers (HCWs) and its variations over time in hospital wards. We wanted to check whether the pandemic had changed the behavior of HCWs. The study was conducted between 1 January 2015, and 31 December 2020. The HCWs were observed to assess their compliance with the Five Moments for Hand Hygiene. We described the percentage of adherence to World Health Organization (WHO) guidelines stratified per year, per specialty areas, per different types of HCWs. We also observed the use of gloves. Descriptive data were reported as frequencies and percentages. We observed 13,494 hand hygiene opportunities. The majority of observations concerned nurses who were confirmed as the category most frequently involved with patients. Hospital's global adherence to WHO guidelines did not change in the last six years. During the pandemic, the rate of adherence to the procedure increased significantly only in Intensive Care Unit (ICU). In 2020, the use of gloves increased in pre-patient contact. The hand-washing permanent monitoring confirmed that it is very difficult to obtain the respect of correct hand hygiene in all opportunities, despite the ongoing pandemic and the fear of contagion.

Care to Quit: a stepped wedge cluster randomised controlled trial to implement best practice smoking cessation care in cancer centres

BACKGROUND

Cigarette smoking in people with cancer is associated with negative treatment-related outcomes including increased treatment toxicity and complications, medication side effects, decreased performance status and morbidity. Evidence-based smoking cessation care is not routinely provided to patients with cancer. The purpose of this study is to determine the effectiveness of a smoking cessation implementation intervention on abstinence from smoking in people diagnosed with cancer.

METHODS

A stepped wedge cluster randomised design will be used. All sites begin in the control condition providing treatment as usual. In a randomly generated order, sites will move to the intervention condition. Based on the Theoretical Domains Framework, implementation of Care to Quit will include (i) building the capability and motivation of a critical mass of key clinical staff and identifying champions; and (ii) identifying and implementing cessation care models/pathways. Two thousand one hundred sixty patients with cancer (diagnosed in the prior six months), aged 18+, who report recent combustible tobacco use (past 90 days or in the 30 days prior to cancer diagnosis) and are accessing anti-cancer therapy, will be recruited at nine sites. Assessments will be conducted at baseline and 7-month follow-up. The primary outcome will be 6-month abstinence from smoking. Secondary outcomes include biochemical verification of abstinence from smoking, duration of quit attempts, tobacco consumption, nicotine dependence, provision and receipt of smoking cessation care, mental health and quality of life and cost effectiveness of the intervention.

DISCUSSION

This study will implement best practice smoking cessation care in cancer centres and has the potential for wide dissemination.

TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN ( ACTRN12621000154808 ) prior to the accrual of the first participant and will be updated regularly as per registry guidelines.

Article 4: Impact assessment of supervision performance assessment and recognition strategy (SPARS) to improve supply chain management in health facilities in Uganda: a national pre and post study

BACKGROUND

To strengthen medicines management capacity, including supply chain management, at public sector health facilities in Uganda, the Ministry of Health introduced a multipronged supervision, performance assessment, and recognition strategy (SPARS). The aim of this study was to assess the impact of SPARS on improving supply chain management. A series of four papers on SPARS described the SPARS concept, its impact on overall and domain practices and appropriate medicines use, and now in the fourth paper describing the effect on supply chain management.

METHODS

District-based health workers trained as supervisors build facility-level capacity in medicines management using an indicator-based performance assessment followed by targeted supervisory visits. From 2010 to 2013, 1222 SPARS visits were implemented, and the SPARS performance indicator scores determined. This article assesses impact on 13 indicators in three of the five SPARS domains-stock management, storage management, and ordering and reporting quality-using a pre-post design. We also explored factors that may have influenced these outcomes.

RESULTS

Between the first and last visit within one year of SPARS implementation, we found an average improvement of 16 percentage points (p < 0.001) in supply chain management measures across all levels of care. The improvement in scores for stock management, storage management, and ordering and reporting was 22 (ns), 16 (p < 0.001), and 11 (p = 0.032) percentage points, respectively. The study identified the key predictors of positive change as a low initial indicator score, frequent supervisory visits, and engagement of the district health officer.

CONCLUSIONS

The multipronged SPARS approach was effective in building supply chain management capacity in lower-level health care facilities with statistically significant improvements in supply chain management overall and in almost all stock and storage- management and ordering and reporting measures after one year of implementation. We recommend broad dissemination of the SPARS approach as an effective strategy to strengthen supply chain management in low-income countries.

TRIAL REGISTRATION

The study did not involve or use human participants or identifiable personal data, human tissue, or animals and thus did not require ethical approval or a waiver. It is a study implemented in collaboration with the Ministry of Health and does not require trial registration.

Developing and Testing a Local Expert-Based Reading Process for Use to Examine Discrepancies Between Guidelines and Current Clinical Practices

The use of relevant guidelines is critical in psychiatric clinical practice to ensure the homogeneity of the global care provided. Consequently, it is important to identify whether they are utilized successfully and, if not, why. This would enable pragmatic solutions to be agreed to improve the organization of care and the removal of any barriers to the guidelines' implementation. The first step in this process, before any exploration of the limitations of the guidelines themselves, involves a determination of whether they are actually applied in clinical practice. We therefore evaluated discrepancies between the guidelines relating to patients with borderline personality disorder and current practices in the psychiatric Emergency Department at Toulouse University Hospital. This was achieved using a reading process involving a panel of eight local experts who analyzed relevant medical files extracted from a database. They were guided by, and instructed to answer, six standardized questions in relation to each file to determine the method's feasibility. A total of 333 files were analyzed to determine whether, in the local experts' judgment, the care provided reflected current guidance. This reading process revealed substantial agreement (0.85%; Fleiss Kappa -0.69), which is a promising outcome and suggests that such methods could be used in future protocols. Moreover, the process is practical and reliable and requires very few materials.

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting

BACKGROUND

Prescribing errors are prevalent in hospital settings with provision of feedback recommended to support prescribing of doctors. Feedback on prescribing has been described as feasible and valued but limited by doctors, with pharmacists described as credible facilitators of prescribing feedback. Evidence supporting prescribing feedback has been limited to date. A formalised programme of pharmacist-led prescribing error feedback was designed and implemented to support prescribers.

OBJECTIVE

To evaluate the impact of a prescribing feedback intervention on prescribing error rates and frequency of prescribing error severity and type.

METHOD

Prospective prescribing audits were undertaken across sixteen hospital wards in a UK teaching hospital over a five day period with 36 prescribers in the intervention group and 41 in the control group. The intervention group received pharmacist-led, individualised constructive feedback on their prescribing, whilst the control group continued with existing practice. Prescribing was re-audited after three months. Prescribing errors were classified by type and severity and data were analysed using relevant statistical tests.

RESULTS

A total of 5191 prescribed medications were audited at baseline and 5122 post-intervention. There was a mean prescribing error rate of 25.0% (SD 16.8, 95% CI 19.3 to 30.7) at baseline and 6.7% (SD 9.0, 95% CI 3.7 to 9.8) post-intervention for the intervention group, and 19.7% (SD 14.5, 95% CI 15.2 to 24.3) at baseline and 25.1% (SD 17.0, 95% CI 19.8 to 30.6) post-intervention for the control group with a significant overall change in prescribing error rates between groups of 23.7% (SD 3.5, 95% CI, -30.6 to -16.8), t(75) = -6.9, p < 0.05. The frequency of each error type and severity rating was reduced in the intervention group, whilst the error frequency of some error types and severity increased in the control group.

CONCLUSION

Pharmacist-led prescribing feedback has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses

AIMS AND OBJECTIVES

To outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses.

BACKGROUND

Medication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses' reporting behaviour and improve medication error reporting rates.

DESIGN

Quasi-experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015-September 2016. One ward from each pair was randomised to either the intervention or control group.

METHOD

Nurses within intervention wards received audit with feedback on a quarterly basis over a 12-month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one-page infographic poster, with content based on medication error data obtained from audits and the hospitals' risk management system (RiskMan). The primary outcome-rate of medication errors reported per month-was determined in both groups at pre-implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link.

RESULTS

A nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre-implementation and implementation phases (80% increase).

CONCLUSIONS

The audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses.

RELEVANCE TO CLINICAL PRACTICE

Despite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.

The role of accountability in the performance of Jazia prime vendor system in Tanzania

Background

Access to safe, effective, quality and affordable essential medicines for all is a central component of Universal Health Coverage (UHC). However, the availability of quality medicines in peripheral healthcare facilities is often limited. Several countries have developed integrated complementary pharmaceutical supply systems to address the shortage of medicines. Nevertheless, there is little evidence on how accountability contributes to the performance of such complementary pharmaceutical supply systems in low-income settings. The current study analyses how accountability mechanisms contributed to the performance of Jazia Prime Vendor System (Jazia PVS) in Tanzania.

Methods

The study analysed financial, performance and procedure accountability as defined in Boven's accountability framework. We conducted 30 in-depth interviews (IDIs), seven group discussions (GD) and 14 focus group discussions (FGDs) in 2018 in four districts that implemented Jazia PVS. We used a deductive and inductive approach to develop the themes and framework analysis to summarize the data.

Results

The study findings revealed that a number of accountability mechanisms implemented in conjunction with Jazia PVS contributed to the performance of Jazia PVS. These include inventory and financial auditing conducted by district pharmacists and the internal auditors, close monitoring of standard operating procedures by the prime vendor regional coordinating office and peer cascade coaching. Furthermore, the auditing activities allowed identifying challenges of delayed payment to the vendor and possible approaches for mitigation while peer cascade coaching played a crucial role in enabling staff at the primary facilities to improve skills to oversee and manage the medicines supply chain.

Conclusion

Financial, performance and procedure accountability measures played an important role for the successful performance of Jazia PVS in Tanzania. The study highlights the need for capacity building linked to financial and supply management at lower level health facilities, including health facility governing committees, which are responsible for priority-setting and decision-making at facility level.

Development and proof-of-concept of a multicenter, patient-centered cancer registry for breast cancer patients with metastatic disease-the "Breast cancer care for patients with metastatic disease" (BRE-4-MED) registry

Background

Patients with metastatic breast cancer (MBC) are treated with a palliative approach with focus on controlling for disease symptoms and maintaining high quality of life. Information on individual needs of patients and their relatives as well as on treatment patterns in clinical routine care for this specific patient group are lacking or are not routinely documented in established Cancer Registries. Thus, we developed a registry concept specifically adapted for these incurable patients comprising primary and secondary data as well as mobile-health (m-health) data.

Methods

The concept for patient-centered “Breast cancer care for patients with metastatic disease” (BRE-4-MED) registry was developed and piloted exemplarily in the region of Main-Franconia, a mainly rural region in Germany comprising about 1.3 M inhabitants. The registry concept includes data on diagnosis, therapy, progression, patient-reported outcome measures (PROMs), and needs of family members from several sources of information including routine data from established Cancer Registries in different federal states, treating physicians in hospital as well as in outpatient settings, patients with metastatic breast cancer and their family members. Linkage with routine cancer registry data was performed to collect secondary data on diagnosis, therapy, and progression. Paper and online-based questionnaires were used to assess PROMs. A dedicated mobile application software (APP) was developed to monitor needs, progression, and therapy change of individual patients. Patient’s acceptance and feasibility of data collection in clinical routine was assessed within a proof-of-concept study.

Results

The concept for the BRE-4-MED registry was developed and piloted between September 2017 and May 2018. In total n = 31 patients were included in the pilot study, n = 22 patients were followed up after 1 month. Record linkage with the Cancer Registries of Bavaria and Baden-Württemberg demonstrated to be feasible. The voluntary APP/online questionnaire was used by n = 7 participants. The feasibility of the registry concept in clinical routine was positively evaluated by the participating hospitals.

Conclusion

The concept of the BRE-4-MED registry provides evidence that combinatorial evaluation of PROMs, needs of family members, and raising clinical parameters from primary and secondary data sources as well as m-health applications are feasible and accepted in an incurable cancer collective.

eHealth Tools to Provide Structured Assistance for Atrial Fibrillation Screening, Management, and Guideline-Recommended Therapy in Metropolitan General Practice: The AF - SMART Study

Background

This eHealth implementation study aimed to evaluate strategies to promote opportunistic atrial fibrillation (AF) screening using electronic screening prompts and improve treatment using electronic decision support (EDS) software.

Methods and Results

An electronic screening prompt appeared whenever an eligible patient's (aged ≥65 years, no AF diagnosis) medical record was opened in participating general practices. General practitioners and practice nurses offered screening using a smartphone ECG, with validated AF algorithm. Guideline‐based EDS was provided to assist treatment decisions. Deidentified data were collected from practices using a data extraction tool. General practices (n=8) across Sydney, Australia, screened for a median of 6 months. A total of 1805 of 11 476 (16%) eligible patients who attended were screened (44% men, mean age 75.7 years). Screening identified 19 (1.1%) new cases of AF (mean age, 79 years; mean CHA₂DS₂‐VASc, 3.7; 53% men). General practitioners (n=30) performed 70% of all screenings (range 1–448 patients per general practitioner). The proportion of patients with AF who had CHA₂DS₂‐VASc ≥2 for men or ≥3 for women prescribed oral anticoagulants was higher for those diagnosed during the study: 15 of 18 (83%) for screen‐detected and 39 of 46 (85%) for clinically detected, compared with 933 of 1306 (71%) patients diagnosed before the study (P<0.001). The EDS was accessed 111 times for patients with AF and for 4 of 19 screen‐detected patients.

Conclusions

The eHealth tools showed promise. Adherence to guideline‐based oral anticoagulant prescription was significantly higher in patients diagnosed during the study period, although the EDS was only used in a minority. While the proportion of eligible patients screened and EDS use was relatively low, further refinements may improve uptake in clinical practice.

Clinical Trial Registration

URL: www.anzctr.org.au. Unique identifier: ACTRN12616000850471.

Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice

Background

Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016–June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice.

Methods

A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory.

Results

GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP ‘screening champion’ had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated.

Conclusions

Introducing an AF screening program is likely to be successful in contexts where there is a senior GP ‘screening champion’, a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke.

Trial registrations

AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry).

AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).

Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial

Background

Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs).

Methods

This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs’ EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes.

Results

Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes.

Conclusions

Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics’ ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs.

Trial registration

ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

Impact of Peer Review in the Radiation Treatment Planning Process: Experience of a Tertiary Care University Hospital in Pakistan

PURPOSE

To evaluate and report the frequency of changes in radiation therapy treatment plans after peer review in a simulation review meeting once a week.

MATERIALS AND METHODS

Between July 1 and August 31, 2016, the radiation plans of 116 patients were discussed in departmental simulation review meetings. All plans were finalized by the primary radiation oncologist before presenting them in the meeting. A team of radiation oncologists reviewed each plan, and their suggestions were documented as no change, major change, minor change, or missing contour. Changes were further classified as changes in clinical target volume, treatment field, or dose. All recommendations were stratified on the basis of treatment intent, site, and technique. Data were analyzed by Statistical Package for the Social Sciences and are presented descriptively.

RESULTS

Out of 116 plans, 26 (22.4%) were recommended for changes. Minor changes were suggested in 15 treatment plans (12.9%) and a major change in 10 (8.6%), and only one plan was suggested for missing contour. The frequency of change recommendations was greater in radical radiation plans than in palliative plans (92.3% v 7.7%). The head and neck was the most common treatment site recommended for any changes (42.3%). Most of the changes were recommended in the technique planned with three-dimensional conformal radiation therapy (50%). Clinical target volume (73.1%) was identified as the most frequent parameter suggested for any change, followed by treatment field (19.2%) and dose (0.08%).

CONCLUSION

Peer review is an important tool that can be used to overcome deficiencies in radiation treatment plans, with a goal of improved and individualized patient care. Our study reports changes in up to a quarter of radiotherapy plans.

Barriers to Implementation of Perinatal Death Audit in Maternity and Pediatric Hospitals in Jordan: Cross-Sectional Study

Background

Perinatal death audit is a feasible and cost-effective quality improvement tool that helps to improve the quality of health care and reduce perinatal deaths. Perinatal death audit is not implemented in almost all hospitals in Jordan.

Objective

This study aimed to assess health professionals’ attitude toward perinatal death auditing and determine the main barriers for effective implementation of perinatal death auditing as perceived by health professionals in Jordanian hospitals.

Methods

A cross-sectional study was conducted among health professionals in 4 hospitals in Jordan. All physicians (pediatricians and obstetricians) and nurses working in these hospitals were invited to participate in the study. The study questionnaire assessed the attitude of health professionals toward perinatal death audit and assessed barriers for implementation of perinatal death audit in their hospitals.

Results

This study included a total of 84 physicians and 218 nurses working in the 4 selected maternity hospitals. Only 35% (29/84) of physicians and 36.2% (79/218) of nurses reported that perinatal death audit would help to improve the quality of prenatal health care services to a great or very great extent. Lack of time was the first-mentioned barrier for implementing perinatal death audit by both physicians (35/84, 42%) and nurses (80/218, 36.7%). Almost the same proportions of health professionals reported inadequate patient information being documented in hospital records as a barrier. Lack of a health information system was the third-mentioned barrier by health professionals. Fear of having conflicts with the family of the dead baby was reported by almost one-third of physicians and nurses. Only 28% (23/83) of physicians and 16.9% (36/213) of nurses reported that they would like to be involved in perinatal death audit in their health facilities.

Conclusions

Health professionals in Jordan had poor attitude toward perinatal death audit. The main barriers for implementing perinatal death audit in Jordanian hospitals were lack of time, inadequate patient information being documented in hospital records, and lack of health information systems.

Improving the management of musculoskeletal conditions: can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study

OBJECTIVES

To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice.

DESIGN

Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series.

SETTING AND PARTICIPANTS

36 general practices in East London.

INTERVENTION

Informed by the results of a Cochrane review on educational interventions to improve general practitioners' (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review.

MAIN OUTCOME MEASURES

Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention.

RESULTS

Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%).

CONCLUSIONS

A quality improvement-based approach to referral management which values GPs' professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.

Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda

The field of implementation science was developed to better understand the factors that facilitate or impede implementation and generate evidence for implementation strategies. In this article, we briefly review progress in implementation science, and suggest five priorities for enhancing the impact of implementation strategies. Specifically, we suggest the need to: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; (4) increase economic evaluations of implementation strategies; and (5) improve the tracking and reporting of implementation strategies. We believe that pursuing these priorities will advance implementation science by helping us to understand when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

Use of Academic Detailing With Audit and Feedback to Improve Antipsychotic Pharmacotherapy

OBJECTIVE

Second-generation antipsychotics vary in their propensity to cause serious cardiometabolic side effects. In addition, use of two or more antipsychotics (polypharmacy) may lead to additive side effects and has not been shown to be consistently more effective than monotherapy. This study examined the use of academic detailing with audit and feedback to improve antipsychotic prescribing practices, including antipsychotic polypharmacy and utilization of medication with high or low risk of cardiometabolic side effects ("high risk" or "low risk," respectively).

METHODS

Four intervention sessions were provided over two years to psychiatric care providers at community mental health centers. Segmented regression within the general estimating equation model framework used Medicaid pharmacy claims to examine prescribing patterns before and after the intervention among all beneficiaries (67,721 person-months) over a five-year period.

RESULTS

After the intervention, 10.9% of beneficiaries with antipsychotic claims were on polypharmacy, compared with 13.1% before the invention. Use of high-risk and low-risk antipsychotics did not change. The final adjusted polypharmacy model showed that antipsychotic polypharmacy decreased among young adults and adults ages 40 or older compared with beneficiaries ages 30-39 (β=-.02, p=.04, and β=-.02, p=.007, respectively). The raw proportion of beneficiaries on high- and low-risk agents did not change, although final adjusted models demonstrated changes in use of high- and low-risk agents by diagnosis and risk group.

CONCLUSIONS

Polypharmacy decreased among young and older adults after academic detailing with audit and feedback. Although further research is needed, this low-intensity intervention may help mental health systems reduce antipsychotic polypharmacy.

Giving and promising gifts: Experimental evidence on reciprocity from the field

We test the value of unconditional non-monetary gifts as a way to improve health worker performance in a low income country health setting. We randomly assigned health workers to different gift treatments within a program that visited health workers, measured performance and encouraged them to provide high quality care for their patients. We show that unconditional non-monetary gifts improve performance by 20 percent over a six-week period, compared to the control group. We compare the impact of the unconditional gift to one in which a gift is offered conditional on meeting a performance target and show that only the unconditional gift results in a statistically significant improvement. This demonstrates that organizations can improve the performance of health workers in the medium term without using financial incentives.

Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia

Purpose

To evaluate the effectiveness of a multifaceted, hospital-wide glycaemic control quality improvement programme.

Methods

The quality improvement intervention comprised three components, derived through root cause analysis: standardising and simplifying care (including evidence-based order sets), increasing visibility (through provider access to clinical data and direct feedback) and educational outreach (directed at the entire institution). Effectiveness was determined at a single urban acute care hospital through time-series analysis with statistical process control charts. Primary outcomes included rate of hyperglycaemia and rate of hypoglycaemia.

Results

The study included 70 992 hospital admissions for 50 404 patients, with 3 35 645 patient days. The hyperglycaemia ratio decreased 25.2% from 14.1% to 10.5% (95% CI 3.3 to 3.9 percentage points, p<0.001). The ratio of patient days with highly elevated blood glucose (>299 mg/dL) decreased 31.8% from 4.8% to 3.3% (95% CI 1.4 to 1.7 percentage points, p<0.001). Hypoglycaemia ratio decreased from 5.2% to 4.6% (95% CI 0.27 to 0.89 percentage points, p<0.001) in patients with diabetes, but increased in patients without diabetes from 1.2% to 1.7% (95% CI 0.46 to 0.70 percentage points, p<0.001).

Conclusions

We demonstrate improved hospital-wide glycaemic control after a multifaceted quality improvement intervention in the context of strong institutional commitment, national mentorship and Lean management

A randomised controlled trial of an online menu planning intervention to improve childcare service adherence to dietary guidelines: a study protocol

INTRODUCTION

The implementation of dietary guidelines in childcare settings is recommended to improve child public health nutrition. However, foods provided in childcare services are not consistent with guidelines. The primary aim of the trial is to assess the effectiveness of a web-based menu planning intervention in increasing the mean number of food groups on childcare service menus that comply with dietary guidelines regarding food provision to children in care.

METHODS AND ANALYSIS

A parallel group randomised controlled trial will be undertaken with 54 childcare services that provide food to children within New South Wales, Australia. Services will be randomised to a 12-month intervention or usual care. The experimental group will receive access to a web-based menu planning and decision support tool and online resources. To support uptake of the web program, services will be provided with training and follow-up support. The primary outcome will be the number of food groups, out of 6 (vegetables, fruit, breads and cereals, meat, dairy and 'discretionary'), on the menu that meet dietary guidelines (Caring for Children) across a 1-week menu at 12-month follow-up, assessed via menu review by dietitians or nutritionists blinded to group allocation. A nested evaluation of child dietary intake in care and child body mass index will be undertaken in up to 35 randomly selected childcare services and up to 420 children aged approximately 3-6 years.

ETHICS AND DISSEMINATION

Ethical approval has been provided by Hunter New England and University of Newcastle Human Research Ethics Committees. This research will provide high-quality evidence regarding the impact of a web-based menu planning intervention in facilitating the translation of dietary guidelines into childcare services. Trial findings will be disseminated widely through national and international peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

Prospectively registered with Australian New Zealand Clinical Trial Registry (ANZCTR) ACTRN12616000974404.

Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal

Background

Each year 700,000 infants die due to intrapartum-related complications. Implementation of Helping Babies Breathe (HBB)-a simplified neonatal resuscitation protocol in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB, as a quality improvement cycle (HBB-QIC), on the retention of neonatal resuscitation skills in a tertiary hospital of Nepal.

Methods

A time-series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills, and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at 6 months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.

Results

One hundred thirty seven health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4 ± 1.4 compared to 12.8 ± 1.6 before (out of 17), and the knowledge was retained 6 months after the training (16.5 ± 1.1). Bag-and-mask skills improved immediately after the training and were retained 6 months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9–13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4–9.7).

Conclusions

Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists, and attended weekly review meetings were more likely to retain their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.

Trial registration

ISRCTN97846009. Date of Registration- 15 August 2012.

Application of the Consolidated Framework for Implementation Research to assess factors that may influence implementation of tobacco use treatment guidelines in the Viet Nam public health care delivery system

Background

Services to treat tobacco dependence are not readily available to smokers in low-middle income countries (LMICs) where smoking prevalence remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of two strategies for implementing tobacco use treatment guidelines in 26 community health centers (CHCs) in Viet Nam. Guided by the Consolidated Framework for Implementation Research (CFIR), prior to implementing the trial, we conducted formative research to (1) identify factors that may influence guideline implementation and (2) inform further modifications to the intervention that may be necessary to translate a model of care delivery from a high-income country (HIC) to the local context of a LMIC.

Methods

We conducted semi-structured qualitative interviews with CHC medical directors, health care providers, and village health workers (VHWs) in eight CHCs (n = 40). Interviews were transcribed verbatim and translated into English. Two qualitative researchers used both deductive (CFIR theory driven) and inductive (open coding) approaches to analysis developed codes and themes relevant to the aims of this study.

Results

The interviews explored four out of five CFIR domains (i.e., intervention characteristics, outer setting, inner setting, and individual characteristics) that were relevant to the analysis. Potential facilitators of the intervention included the relative advantage of the intervention compared with current practice (intervention characteristics), awareness of the burden of tobacco use in the population (outer setting), tension for change due to a lack of training and need for skill building and leadership engagement (inner setting), and a strong sense of collective efficacy to provide tobacco cessation services (individual characteristics). Potential barriers included the perception that the intervention was more complex (intervention characteristic) and not necessarily compatible (inner setting) with current workflows and staffing historically designed to address infectious disease prevention and control rather than chronic disease prevention and competing priorities that are determined by the MOH (outer setting).

Conclusions

In this study, CFIR provided a valuable framework for evaluating factors that may influence implementation of a systems-level intervention for tobacco control in a LMIC and understand what adaptations may be needed to translate a model of care delivery from a HIC to a LMIC.

Trial registration

NCT02564653. Registered September 2015

The International College of Neuropsychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 1: Background and Methods of the Development of Guidelines

BACKGROUND

This paper includes a short description of the important clinical aspects of Bipolar Disorder with emphasis on issues that are important for the therapeutic considerations, including mixed and psychotic features, predominant polarity, and rapid cycling as well as comorbidity.

METHODS

The workgroup performed a review and critical analysis of the literature concerning grading methods and methods for the development of guidelines.

RESULTS

The workgroup arrived at a consensus to base the development of the guideline on randomized controlled trials and related meta-analyses alone in order to follow a strict evidence-based approach. A critical analysis of the existing methods for the grading of treatment options was followed by the development of a new grading method to arrive at efficacy and recommendation levels after the analysis of 32 distinct scenarios of available data for a given treatment option.

CONCLUSION

The current paper reports details on the design, method, and process for the development of CINP guidelines for the treatment of Bipolar Disorder. The rationale and the method with which all data and opinions are combined in order to produce an evidence-based operationalized but also user-friendly guideline and a specific algorithm are described in detail in this paper.

Implementation of a New Intravenous Insulin Method on Intermediate-Care Units in Hospitalized Patients

Good blood glucose control in hospitalized adults leads to reduced mortality. Intravenous (IV) insulin has been shown to be an effective way to achieve tight control of blood glucose. Managing IV insulin is a labor-intensive task for nurses and is generally done in intensive care units with high nurse-to-patient ratios. In this 3-month study, intermediate-care general medicine units with a nurse-to-patient ratio of 1 to 5 or 6 were evaluated for effectiveness of monitoring IV insulin. The project, which relied on intensive in-service education, an audit tool, and continuous positive feedback for nurses, yielded positive results.

The use of patient experience survey data by out-of-hours primary care services: a qualitative interview study

BACKGROUND

English National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done.

OBJECTIVES

We explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS).

METHODS

A qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews.

RESULTS

Although most providers regularly audited their patients' experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form.

CONCLUSIONS

The lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed.

Knowledge Translation Interventions to Improve the Timing of Dialysis Initiation: Protocol for a Cluster Randomized Trial

Background:

Early initiation of chronic dialysis (starting dialysis with higher vs lower kidney function) has risen rapidly in the past 2 decades in Canada and internationally, despite absence of established health benefits and higher costs. In 2014, a Canadian guideline on the timing of dialysis initiation, recommending an intent-to-defer approach, was published.

Objective:

The objective of this study is to evaluate the efficacy and safety of a knowledge translation intervention to promote the intent-to-defer approach in clinical practice.

Design:

This study is a multicenter, 2-arm parallel, cluster randomized trial.

Setting:

The study involves 55 advanced chronic kidney disease clinics across Canada.

Patients:

Patients older than 18 years who are managed by nephrologists for more than 3 months, and initiate dialysis in the follow-up period are included in the study.

Measurements:

Outcomes will be measured at the patient-level and enumerated within a cluster. Data on characteristics of each dialysis start will be determined by linkages with the Canadian Organ Replacement Register. Primary outcomes include the proportion of patients who start dialysis early with an estimated glomerular filtration rate greater than 10.5 mL/min/1.73 m² and start dialysis in hospital as inpatients or in an emergency room setting. Secondary outcomes include the rate of change in early dialysis starts; rates of hospitalizations, deaths, and cost of predialysis care (wherever available); quarterly proportion of new starts; and acceptability of the knowledge translation materials.

Methods:

We randomized 55 multidisciplinary chronic disease clinics (clusters) in Canada to receive either an active knowledge translation intervention or no intervention for the uptake of the guideline on the timing of dialysis initiation. The active knowledge translation intervention consists of audit and feedback as well as patient- and provider-directed educational tools delivered at a comprehensive in-person medical detailing visit. Control clinics are only exposed to guideline release without active dissemination. We hypothesize that the clinics randomized to the intervention group will have a lower proportion of early dialysis starts.

Limitations:

Limitations include passive dissemination of the guideline through publication, and lead-time and survivor bias, which favors delayed dialysis initiation.

Conclusions:

If successful, this active knowledge translation intervention will reduce early dialysis starts, lead to health and economic benefits, and provide a successful framework for evaluating and disseminating future guidelines.

Trial Registration:

ClinicalTrials.gov, NCT02183987

Effectiveness of computerized point-of-care reminders on adherence with multiple clinical recommendations by primary health care providers: protocol for a cluster-randomized controlled trial

BACKGROUND

To determine the effectiveness of reminders compared to no reminders in improving adherence to multiple clinical recommendations measured as the resolution of the clinical condition that motivated the reminder, in a primary care setting with a well-established feedback system.

METHODS/DESIGN

A 12-month, cluster-randomized, controlled clinical trial was designed (randomized by primary care team) to evaluate the impact of computerized reminders. All study participants will continue to receive the usual feedback from the electronic health records system. The control group (well-established feedback) will be compared with reminders and a well-established feedback system. The study will include all general practitioners (3425) and nurses (3262) providing primary care for a population aged 14 years or older in the 282 primary care teams reporting to the Catalan Institute of Health. Up to 10 clinical reminders are offered for each patient, recommending action related to at least one of nine clinical conditions: arterial hypertension, elevated cardiovascular risk, type 2 diabetes mellitus, cerebrovascular accident, ischemic heart disease, heart failure, atrial fibrillation, smoking habit, and hepatitis C. The outcomes are the resolution of the clinical condition that motivated the reminder and the time elapsed between the first reminder message and implementation of the recommended action (months). Due to the obvious correlation between reminders about the same patient, the profile of patients assigned to a particular professional, and the professionals assigned to a particular centre, hierarchical modelling will be used to simultaneously estimate the effect of the study variables at these different levels of analysis. To estimate the impact of the intervention arm, an analysis of adherence to each type of reminder will be carried out, using multi-level logistical regression models at level of the primary care centre. Time to adherence will be estimated by the Kaplan-Meier method and comparisons will be done using the log-rank test.

DISCUSSION

The results of this study could provide new evidence on the impact of computerized reminders at the point of care on adherence to clinical guidelines in primary care with an established feedback system. Trial registration ISRCTN42391639. October 8, 2012.

Impact of monitoring surgical prophylactic antibiotics and a computerized decision support system on antimicrobial use and antimicrobial resistance

BACKGROUND

Monitoring of performance indicators and implementation of a computerized decision support system (CDSS) have been suggested as effective measures to improve quality of care. We conducted this study to evaluate the effect of monitoring of surgical prophylactic antibiotics (SPAs) and the CDSS on the antimicrobial use and resistance rate of major nosocomial pathogens.

METHODS

An interrupted time series with segmented regression analysis in 3 periods (preintervention, SPAs monitoring, and CDSS) was conducted in a tertiary care hospital. Immediate change and change in trends of antimicrobial use density, resistance rate of nosocomial pathogens, and cost of antibiotics in each intervention period were compared with those of the preintervention period.

RESULTS

Compared with the preintervention period, the change in the slope of the total use of antibiotics was -8.71 defined daily dose (DDD) per 1,000 patient days per month (95% confidence interval [CI], -11.43 to -5.98; P < .01) in the SPAs monitoring period and -1.95 DDD per 1,000 patient days per month (95% CI, -2.93 to -0.96; P < .01) in the CDSS period. Use of third-generation cephalosporins and aminoglycosides showed change comparable with that of total antibiotics use, but use of vancomycin and carbapenem was unchanged in the CDSS period. Trends of the proportions of extended-spectrum β-lactamase-producing Escherichia coli, meropenem-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus have been reversed or decreased in slope in the CDSS period. Length of hospital stay also showed a negative change in slope in the CDSS period.

CONCLUSIONS

Monitoring of SPAs and implementation of the CDSS can be effective measures for antimicrobial stewardship.

Impact on Maternity Professionals of Novel Approaches to Clinical Audit Feedback

The authors compared three approaches to feedback of clinical audit findings relating to miscarriage in 15 Scottish maternity services (printed report alone; report plus action planning letter; report plus face-to-face facilitated action planning). Clinicians were surveyed to measure theory of planned behavior constructs (in the context of two audit criteria) before and after feedback ( n = 253) and assessed perceptions of the audit through in-depth interviews ( n = 17). Prefeedback, clinicians had positive attitudes and strong subjective norms and intentions to comply, although perceived behavioral control was lower. Generally, positive attitudes, subjective norms, and intentions increased after feedback but for one of the two criteria (providing a 7-day miscarriage service), perceived behavioral control decreased. No changes over time reached statistical significance, and analysis of covariance (adjusting for prefeedback scores) showed no consistent relationships between method of feedback and postfeedback construct scores. Interviews revealed positive perceptions of audit but frustration at lack of capacity to implement changes. Although interventions that increased intensity of feedback proved feasible and acceptable to clinicians, the authors were unable to demonstrate that they increased intention to comply with audit criteria.

Which Measures of Health Status Assessment are the Most Significant in Organized Cohorts with Low Current Cardiovascular Risk? The Screening Study of Penitentiary Staff in Saratov Region, Russia

OBJECTIVE

The aim of the present study was to compare different methods of health status assessment in organized cohort of penitentiary employees in Saratov Region, Russian Federation.

MATERIALS AND METHODS

1,014 penitentiary employees (81.8% male) aged 33.4±6.8 years were included in the cohort study. All participants underwent an annual preventive health examination in the Center of Medical and Social Rehabilitation of Russian Federal Penitentiary Service in Saratov Region. The prevalence of common cardiovascular risk factors was assessed. Risk Score and the number of fulfilled health metrics proposed by American Heart Association (AHA) were calculated for each participant.

RESULTS

It is shown that penitentiary staff in Saratov Region is characterized by low current risk score (1.2±0.8%), but high prevalence of such risk factors as increased body weight and obesity (51%), tobacco use or passive smoking (81%), and unhealthy diet (55%). 98.4% of participants had the Score level of ≤5%, but only 4.5% of penitentiary staff met the ideal cardiovascular health (they met all seven AHA health metrics). One fifth of the participants met three or less AHA health metrics. A statistically significant correlation between the risk Score and the number of fulfilled AHA health metrics is revealed (Chi-square = 5.1, p=0.024). The probability of fulfilment of less than 5 AHA health metrics in subjects with medium risk score is shown to be almost twofold greater than in subjects with low risk Score. However, there are a lot of differences in the assessment of cardiovascular health by risk Score and AHA health metrics.

CONCLUSION

AHA health metrics are more preferable than the risk Score or assessment of separate cardiovascular risk factors for preventive management in organized cohorts with low current cardiovascular risk such as penitentiary staff in Saratov Region.

Study protocol for "Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)": a pragmatic trial comparing implementation strategies

BACKGROUND

Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting.

METHODS/DESIGN

This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations. The strategies are as follows: (arm 1) a toolkit, presented in paper and electronic form, which includes a training webinar; (arm 2) toolkit plus in-person training with a focus on practice change and change management strategies; and (arm 3) toolkit, in-person training, plus practice facilitation with on-site visits. We use a mixed methods approach to data collection and analysis: (i) baseline surveys on study clinic characteristics, to explore how these characteristics impact the clinics' ability to implement the tools and the effectiveness of each implementation strategy; (ii) quantitative data on change in rates of guideline-concordant prescribing; and (iii) qualitative data on the "how" and "why" underlying the quantitative results. The outcomes of interest are clinic-level results, categorized using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, within an interrupted time-series design with segmented regression models. This pragmatic trial will compare how well each implementation strategy works in "real-world" practices.

DISCUSSION

Having a better understanding of how different strategies support implementation efforts could positively impact the field of implementation science, by comparing practical, generalizable methods for implementing clinical innovations in community health centers. Bridging this gap in the literature is a critical step towards the national long-term goal of effectively disseminating and implementing effective interventions into community health centers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02325531.

Evaluation of a continuous monitoring and feedback initiative to improve quality of anaesthetic care: a mixed-methods quasi-experimental study

Background

This study evaluated the impact of a continuous quality monitoring and feedback initiative in anaesthesia.

Objectives

To conduct a quasi-experimental evaluation of the feedback initiative and its effect on quality of anaesthetic care and perioperative efficiency. To understand the longitudinal effects of passive and active feedback and investigate the mechanisms and interactions underpinning those effects.

Design

Mixed-methods evaluation with analysis and synthesis of data from longitudinal qualitative interviews, longitudinal evaluative surveys and an interrupted time series study.

Intervention

Continuous measurement of a range of anaesthetic quality indicators was undertaken in a London teaching hospital alongside monthly personal feedback from case summary data to a cohort of anaesthetists, with follow-up roll-out to the whole NHS trust. Basic feedback consisted of the provision of passive monthly personalised feedback reports containing summary case data. In the enhanced phase, data feedback consisted of more sophisticated statistical breakdown of data, comparative and longitudinal views, and was paired with an active programme of dissemination and professional engagement.

Methods

Baseline data collection began in March 2010. Implementation of basic feedback took place in October 2010, followed by implementation of the enhanced feedback protocol in July 2012. Weekly aggregated quality indicator data, coupled with surgical site infection and mortality rates, was modelled using interrupted time series analyses. The study anaesthetist cohort comprised 50,235 cases, performed by 44 anaesthetists over the course of the study, with 22,670 cases performed at the primary site. Anaesthetist responses to the surveys were collected pre and post implementation of feedback at all three sites in parallel with qualitative investigation. Seventy anaesthetists completed the survey at one or more time points and 35 health-care professionals, including 24 anaesthetists, were interviewed across two time points.

Results

Results from the time series analysis of longitudinal variation in perioperative indicators did not support the hypothesis that implementation of basic feedback improved quality of anaesthetic care. The implementation of enhanced feedback was found to have a significant positive impact on two postoperative pain measures, nurse-recorded freedom from nausea, mean patient temperature on arrival in recovery and Quality of Recovery Scale scores. Analysis of survey data demonstrated that anaesthetists value perceived credibility of data and local relevance of quality indicators above other criteria when assessing utility of feedback. A significant improvement in the perceived value of quality indicators, feedback, data use and overall effectiveness was observed between baseline and implementation of feedback at the primary site, a finding replicated at the two secondary sites. Findings from the qualitative research elucidated processes of interaction between context, intervention and user, demonstrating a positive response by clinicians to this type of initiative and willingness to interact with a sustained and comprehensive feedback protocol to understand variations in care.

Conclusions

The results support the potential of quality monitoring and feedback interventions as quality improvement mechanisms and provide insight into the positive response of clinicians to this type of initiative, including documentation of the experiences of anaesthetists that participated as users and codesigners of the feedback. Future work in this area might usefully investigate how this type of intervention may be transferred to other areas of clinical practice and further explore interactions between local context and the successful implementation of quality monitoring and feedback systems.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: protocol of a randomised controlled trial

INTRODUCTION

A number of jurisdictions internationally have policies requiring schools to implement healthy canteens. However, many schools have not implemented such policies. One reason for this is that current support interventions cannot feasibly be delivered to large numbers of schools. A promising solution to support population-wide implementation of healthy canteen practices is audit and feedback. The effectiveness of this strategy has, however, not previously been assessed in school canteens. This study aims to assess the effectiveness and cost-effectiveness of an audit and feedback intervention, delivered by telephone and email, in increasing the number of school canteens that have menus complying with a government healthy-canteen policy.

METHODS AND ANALYSIS

Seventy-two schools, across the Hunter New England Local Health District in New South Wales Australia, will be randomised to receive the multicomponent audit and feedback implementation intervention or usual support. The intervention will consist of between two and four canteen menu audits over 12 months. Each menu audit will be followed by two modes of feedback: a written feedback report and a verbal feedback/support via telephone. Primary outcomes, assessed by dieticians blind to group status and as recommended by the Fresh Tastes @ School policy, are: (1) the proportion of schools with a canteen menu containing foods or beverages restricted for sale, and; (2) the proportion of schools that have a menu which contains more than 50% of foods classified as healthy canteen items. Secondary outcomes are: the proportion of menu items in each category ('red', 'amber' and 'green'), canteen profitability and cost-effectiveness.

ETHICS AND DISSEMINATION

Ethical approval has been obtained by from the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. The findings will be disseminated in usual forums, including peer-reviewed publication and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12613000543785.

Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care

BACKGROUND

This paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized trials of audit and feedback compared to usual care, with objectively measured outcomes assessing compliance with intended professional practice. Two reviewers independently screened articles and abstracted variables related to the intervention, the context, and trial methodology. The median absolute risk difference in compliance with intended professional practice was determined for each study, and adjusted for baseline performance. The effect size across studies was recalculated as studies were added to the cumulative analysis. Meta-regressions were conducted for studies published up to 2002, 2006, and 2010 in which characteristics of the intervention, the recipients, and trial risk of bias were tested as predictors of effect size.

RESULTS

Of the 140 randomized clinical trials (RCTs) included in the Cochrane review, 98 comparisons from 62 studies met the criteria for inclusion. The cumulative analysis indicated that the effect size became stable in 2003 after 51 comparisons from 30 trials. Cumulative meta-regressions suggested new trials are contributing little further information regarding the impact of common effect modifiers. Feedback appears most effective when: delivered by a supervisor or respected colleague; presented frequently; featuring both specific goals and action-plans; aiming to decrease the targeted behavior; baseline performance is lower; and recipients are non-physicians.

DISCUSSION

There is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field. There are opportunity costs for patients, providers, and health care systems when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.