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Wilmont I, Loeffen M, Hoogeboom T. A qualitative study on the facilitators and barriers to adopting the N-of-1 trial methodology as part of clinical practice: potential versus implementation challenges. Int J Qual Stud Health Well-being 2024; 19:2318810. [PMID: 38417032 PMCID: PMC10903748 DOI: 10.1080/17482631.2024.2318810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/10/2024] [Indexed: 03/01/2024] Open
Abstract
PURPOSE To investigate opinions among healthcare stakeholders whether implementation of the N-of-1 trial approach in clinical practice is a feasible way to optimize evidence-based treatment results for unique patients. METHODS We interviewed clinicians, researchers, and a patient advocate (n = 13) with an interest in or experience with N-of-1 trials on the following topics: experience with N-of-1, measurement, validity and reliability, informally gathered data usability, and influence on physician-patient relationship. Interviews were analysed using qualitative, thematic analysis. RESULTS The N-of-1 approach has the potential to shift the current healthcare system towards embracing personalized medicine. However, its application in clinical practice carries significant challenges in terms of logistics, time investment and acceptability. New skills will be required from patients and healthcare providers, which may alter the patient-physician relationship. The rise of consumer technology enabling self-measurement may leverage the uptake of N-of-1 approaches in clinical practice. CONCLUSIONS There is a strong belief that the N-of-1 approach has the potential to play a prominent role in transitioning the current healthcare system towards embracing personalized medicine. However, there are many barriers deeply ingrained in our healthcare system that hamper the uptake of the N-of-1 approach, making it momentarily only interesting for research purposes.
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Affiliation(s)
- Ilona Wilmont
- Data & Knowledge Engineering, HAN University of Applied Sciences, Arnhem, the Netherlands
- Institute for Computing and Information Sciences, Data Science, Radboud University Nijmegen, Nijmegen, the Netherlands
| | | | - Thomas Hoogeboom
- IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Evrard P, Henrard S, Spinewine A. Development of a Behavior-Change Intervention toward Benzodiazepine Deprescribing in Older Adults Living in Nursing Homes. J Am Med Dir Assoc 2024; 25:105053. [PMID: 38838741 DOI: 10.1016/j.jamda.2024.105053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE We aimed to develop a context-specific intervention toward benzodiazepine deprescribing in nursing homes (NHs), with insights from behavior-change theories and involvement of stakeholders. DESIGN Selection of behavior change techniques (BCTs), through online survey and group discussion, followed by operationalization of these BCTs into intervention components. SETTING AND PARTICIPANTS The intervention was developed for Belgian NHs, involving various stakeholders: health care professionals (HCPs), NH administrators, and policy makers. METHODS Using the Theory and Techniques Tool, we preselected the BCTs linked to one of the 9 Theoretical Domain Framework domains identified as being the main barriers for benzodiazepine deprescribing in Belgian NHs. These were then presented to stakeholders. Based on the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Ethics) criteria, participants ranked BCTs through an online survey, and then performed final selection during a group discussion. Selected BCTs were operationalized into intervention components, with specific contents and methods of delivery validated by stakeholders. RESULTS Thirty-seven potential BCTs were identified. Eighteen stakeholders participated in the survey, and 7 in the group discussion. This led to the final inclusion of 9 BCTs: instruction on how to perform the behavior, information about health consequences, pros and cons, problem solving, goal setting (behavior), social comparison, restructuring physical environment, restructuring social environment, and graded tasks. These BCTs were operationalized into a 6-component intervention: process and goal setting, HCP education, physical environment adaptations, audit and feedback, NH residents' and relatives' increased awareness, and multidisciplinary work. CONCLUSION AND IMPLICATIONS Use of a theory-based approach toward intervention development has the potential to improve the probability of its feasibility and effectiveness in tackling barriers to benzodiazepine deprescribing. By doing so, we have developed a multifaceted approach with actions taken at the patient, HCP, and NH levels. Our novel 6-component intervention will be evaluated in a pilot cluster-randomized controlled trial to assess its feasibility.
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Affiliation(s)
- Perrine Evrard
- Clinical Pharmacy and Pharmacoepidemiology Research Group, Louvain Drug Research Institute, UCLouvain, Brussels, Belgium.
| | - Séverine Henrard
- Clinical Pharmacy and Pharmacoepidemiology Research Group, Louvain Drug Research Institute, UCLouvain, Brussels, Belgium; Institute of Health and Society (IRSS), UCLouvain, Brussels, Belgium
| | - Anne Spinewine
- Clinical Pharmacy and Pharmacoepidemiology Research Group, Louvain Drug Research Institute, UCLouvain, Brussels, Belgium; Pharmacy Department, CHU UCL Namur, UCLouvain, Yvoir, Belgium
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Jagesar AR, Otten M, Dam TA, Biesheuvel LA, Dongelmans DA, Brinkman S, Thoral PJ, François-Lavet V, Girbes ARJ, de Keizer NF, de Grooth HJS, Elbers PWG. Comparative performance of intensive care mortality prediction models based on manually curated versus automatically extracted electronic health record data. Int J Med Inform 2024; 188:105477. [PMID: 38743997 DOI: 10.1016/j.ijmedinf.2024.105477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Benchmarking intensive care units for audit and feedback is frequently based on comparing actual mortality versus predicted mortality. Traditionally, mortality prediction models rely on a limited number of input variables and significant manual data entry and curation. Using automatically extracted electronic health record data may be a promising alternative. However, adequate data on comparative performance between these approaches is currently lacking. METHODS The AmsterdamUMCdb intensive care database was used to construct a baseline APACHE IV in-hospital mortality model based on data typically available through manual data curation. Subsequently, new in-hospital mortality models were systematically developed and evaluated. New models differed with respect to the extent of automatic variable extraction, classification method, recalibration usage and the size of collection window. RESULTS A total of 13 models were developed based on data from 5,077 admissions divided into a train (80%) and test (20%) cohort. Adding variables or extending collection windows only marginally improved discrimination and calibration. An XGBoost model using only automatically extracted variables, and therefore no acute or chronic diagnoses, was the best performing automated model with an AUC of 0.89 and a Brier score of 0.10. DISCUSSION Performance of intensive care mortality prediction models based on manually curated versus automatically extracted electronic health record data is similar. Importantly, our results suggest that variables typically requiring manual curation, such as diagnosis at admission and comorbidities, may not be necessary for accurate mortality prediction. These proof-of-concept results require replication using multi-centre data.
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Affiliation(s)
- A R Jagesar
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands.
| | - M Otten
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - T A Dam
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - L A Biesheuvel
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - D A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - S Brinkman
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute and National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
| | - P J Thoral
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - V François-Lavet
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - A R J Girbes
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - N F de Keizer
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute and National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
| | - H J S de Grooth
- Intensive Care Center, UMC Utrecht, Utrecht, The Netherlands
| | - P W G Elbers
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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Fu M, Gong Z, Zhu Y, Li C, Li H, Shi L, Guan X. Disparity in Guideline-Based Antidiabetic Drugs Prescribing for Type 2 Diabetes Patients in Primary Healthcare Facilities Across China, 2017-2019. Pharmacoepidemiol Drug Saf 2024; 33:e5882. [PMID: 39092465 DOI: 10.1002/pds.5882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/10/2024] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE The purpose of this study is to evaluate the pattern, appropriateness, and cost of antidiabetic drugs prescribed for patients with Type 2 diabetes at primary healthcare facilities (PHFs) in China. METHODS We collected outpatient-visit prescriptions from 363 PHFs in 31 cities covering eastern, central, and western regions of China. The visits of adult patients with Type 2 diabetes diagnosis were collected and classified the antidiabetic medication pattern of each patient use as recommended or non-recommended according to Chinese guidelines. We then calculated the proportion of guideline-recommended patterns and the average monthly cost for each pattern, overall and by region. RESULTS Of 33 519 prescriptions for Type 2 diabetes, most (73.9%) were for guideline-recommended antidiabetic treatments. The proportion of guideline-recommended prescriptions varied by region (eastern [75.9%], central [87.5%], and western [59.7%]). Metformin monotherapy was the most common guideline-recommended treatment in all three regions (eastern [20.1%], central [28.0%], and western [24.6%]). The most common non-guideline-recommended treatments were monotherapy of insulin (eastern [16.5%], central [5.1%], and western [25.7%]) and traditional Chinese antidiabetic medicines (eastern [5.6%], central [5.7%], and western [11.1%]). The average monthly costs were lower for guideline-recommended treatments compared to non-recommended treatments in all regions (eastern [13.6 ± 15.4 USD vs. 28.1 ± 22.0 USD], central [9.8 ± 10.9 USD vs. 28.7 ± 19.4 USD], and western [17.9 ± 21.4 USD vs. 30.3 ± 23.6 USD]). CONCLUSIONS The majority of patients with Type 2 diabetes received guideline-recommended antidiabetic medications at PHFs in China, with only half of the prescriptions containing guideline-recommended metformin. Utilization of guideline-recommended therapies differed across regions. Tailored interventions to promote evidence-based antidiabetic prescribing are urgently needed, especially in the undeveloped western region.
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Affiliation(s)
- Mengyuan Fu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Zhiwen Gong
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yuezhen Zhu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Can Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huangqianyu Li
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
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Piovano E, Puppo A, Camanni M, Castiglione A, Delpiano EM, Giacometti L, Rolfo M, Rizzo A, Zola P, Ciccone G, Pagano E. Implementing Enhanced Recovery After Surgery for hysterectomy in a hospital network with audit and feedback: A stepped-wedge cluster randomised trial. BJOG 2024; 131:1207-1217. [PMID: 38404145 DOI: 10.1111/1471-0528.17797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of implementing the Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing elective hysterectomy in a network of regional hospitals, supported by an intensive audit-and-feedback (A&F) approach. DESIGN A multi-centre, stepped-wedge cluster randomised trial (ClinicalTrials.gov NCT04063072). SETTING Gynaecological units in the Piemonte region, Italy. POPULATION Patients undergoing elective hysterectomy, either for cancer or for benign conditions. METHODS Twenty-three units (clusters), stratified by surgical volume, were randomised into four sequences. At baseline (first 3 months), standard care was continued in all units. Subsequently, the four sequences implemented the ERAS protocol successively every 3 months, after specific training. By the end of the study, each unit had a period in which standard care was maintained (control) and a period in which the protocol, supported by feedback, was applied (experimental). MAIN OUTCOME MEASURES Length of hospital stay (LOS), without outliers (>98th percentile). RESULTS Between September 2019 and May 2021, 2086 patients were included in the main analysis with an intention-to-treat approach: 1104 (53%) in the control period and 982 (47%) in the ERAS period. Compliance with the ERAS protocol increased from 60% in the control period to 76% in the experimental period, with an adjusted absolute difference of +13.3% (95% CI 11.6% to 15.0%). LOS, moving from 3.5 to 3.2 days, did not show a significant reduction (-0.12 days; 95% CI -0.30 to 0.07 days). No difference was observed in the occurrence of complications. CONCLUSIONS Implementation of the ERAS protocol for hysterectomy at the regional level, supported by an A&F approach, resulted in a substantial improvement in compliance, but without meaningful effects on LOS and complications. This study confirms the effectiveness of A&F in promoting important innovations in an entire hospital network and suggests the need of a higher compliance with the ERAS protocol to obtain valuable improvements in clinical outcomes.
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Affiliation(s)
- Elisa Piovano
- Obstetrics and Gynaecology Unit 2U, Sant'Anna Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Andrea Puppo
- Obstetrics and Gynaecology Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Marco Camanni
- Obstetrics and Gynaecology Unit, Martini Hospital, ASL Città di Torino, Turin, Italy
| | - Anna Castiglione
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Elena Maria Delpiano
- Obstetrics and Gynaecology Unit, Martini Hospital, ASL Città di Torino, Turin, Italy
| | - Lisa Giacometti
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Monica Rolfo
- Healthcare Services Direction, Humanitas Gradenigo, Torino, Italy
| | - Alessio Rizzo
- General Surgery and Oncology Unit, Mauriziano Hospital, Turin, Italy
| | - Paolo Zola
- Department of Surgical Sciences, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - Giovannino Ciccone
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Eva Pagano
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
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George LS, Duberstein PR, Keating NL, Bates B, Bhagianadh D, Lin H, Saraiya B, Goel S, Akincigil A. Estimating oncologist variability in prescribing systemic cancer therapies to patients in the last 30 days of life. Cancer 2024. [PMID: 39077884 DOI: 10.1002/cncr.35488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation. RESULTS Patients' median age at the time of death was 74 years (interquartile range, 69-79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end-of-life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end-of-life cancer therapy (OR, 4.42; 95% CI, 4.00-4.89). CONCLUSIONS Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies.
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Affiliation(s)
| | | | | | | | | | - Haiqun Lin
- Rutgers University, New Brunswick, New Jersey, USA
| | | | - Sanjay Goel
- Rutgers University, New Brunswick, New Jersey, USA
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Smits GH, Bots ML, Hollander M, Wit AD, van Doorn S. Practice visitations in primary care to improve performance of cardiovascular risk management: an observational study. BJGP Open 2024:BJGPO.2023.0213. [PMID: 38479757 DOI: 10.3399/bjgpo.2023.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/06/2024] [Accepted: 02/20/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Despite programmatic protocolised care and structured support, considerable variation is observed in completeness of registration and achieving targets of cardiovascular risk management (CVRM) between individual GPs in the Netherlands. AIM To determine whether completeness of registration and achieved targets of cardiovascular risk factors improves with practice visitation. DESIGN & SETTING Observational study utilising the care group's database (2016-2019), comparing changes in registration and achieved targets in non-visited practices and visited practices. METHOD We compared completeness scores of registration and scores of targets achieved before visitation and 1 year after visitation. Data were analysed on patient level and GP level. Separate analyses were performed among GPs who were ranked in the lower 25% of score distributions. RESULTS We observed no clinically relevant improvements in completeness of registration and targets achieved in 2017, 2018, and 2019 that could be attributed to visitations in the previous year, both on individual patient level and on aggregated level per general practice. In practices ranked in the lower 25% of the distribution, improvements over time were clinically relevant and larger than the overall changes. Yet, these findings were irrespective of the number of practice visitations. CONCLUSION Practice visitations in our setting did not seem to lead to improvements in practice performance, nor in completeness of registration of risk factors or in reaching predefined target goals for cardiovascular risk factors.
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Affiliation(s)
- Geert Hjm Smits
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ardine de Wit
- Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Ambasta A, Holroyd-Leduc JM, Pokharel S, Mathura P, Shih AWY, Stelfox HT, Ma I, Harrison M, Manns B, Faris P, Williamson T, Shukalek C, Santana M, Omodon O, McCaughey D, Kassam N, Naugler C. Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization. Implement Sci 2024; 19:45. [PMID: 38956637 PMCID: PMC11221016 DOI: 10.1186/s13012-024-01376-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. METHODS We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. DISCUSSION The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. TRIAL REGISTRATION This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic. CLINICALTRIALS gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.
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Affiliation(s)
- Anshula Ambasta
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Department of Anesthesia, Pharmacology and Therapeutics, Therapeutics Initiative, University of British Columbia, Vancouver, V6T 1Z4, Canada.
| | - Jayna M Holroyd-Leduc
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Surakshya Pokharel
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Pamela Mathura
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Andrew Wei-Yeh Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Henry T Stelfox
- Faculty of Medicine and Dentistry, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Irene Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Braden Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Caley Shukalek
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Maria Santana
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Onyebuchi Omodon
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Deirdre McCaughey
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Chris Naugler
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
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Dufour E, Duhoux A. How can strategies based on performance measurement and feedback support changes in nursing practice? A theoretical reflection drawing on Habermas' social perspective. Nurs Inq 2024; 31:e12628. [PMID: 38409735 DOI: 10.1111/nin.12628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/28/2024]
Abstract
Strategies based on performance measurement and feedback are commonly used to support quality improvement among nurses. These strategies require practice change, which, for nurses, rely to a large extent on their capacity to coordinate with each other effectively. However, the levers for coordinated action are difficult to mobilize. This discussion paper offers a theoretical reflection on the challenges related to coordinating nurses' actions in the context of practice changes initiated by performance measurement and feedback strategies. We explore how Jürgen Habermas' theory of Communicative Action may shed light on the issues underlying nurses' collective actions and self-determination in practice change and the implications for the design of strategies based on performance measurement and feedback. Based on this theory, we propose differences between communicative and functional coordination according to the nature of the actions and the purposes involved. The domains of action underlying these coordination processes, which Habermas referred to as the lifeworld and the system, are then used to draw a parallel with aspects of nursing practice. Further exploration of these concepts allows us to consider the tensions between the demands of the system and the self-determination of nurses within their practice.
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Affiliation(s)
- Emilie Dufour
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada
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Kovács I, Székely T, Pogány P, Takács S, Erős M, Járay B. Utilizing the open-source programming language Python to create interactive Quality Assurance dashboards for diagnostic and screening performance in Cytology. J Am Soc Cytopathol 2024; 13:309-318. [PMID: 38702208 DOI: 10.1016/j.jasc.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Effective feedback on cytology performance relies on navigating complex laboratory information system data, which is prone to errors and lacks flexibility. As a comprehensive solution, we used the Python programming language to create a dashboard application for screening and diagnostic quality metrics. MATERIALS AND METHODS Data from the 5-year period (2018-2022) were accessed. Versatile open-source Python libraries (user developed program code packages) were used from the first step of LIS data cleaning through the creation of the application. To evaluate performance, we selected 3 gynecologic metrics: the ASC/LSIL ratio, the ASC-US/ASC-H ratio, and the proportion of cytologic abnormalities in comparison to the total number of cases (abnormal rate). We also evaluated the referral rate of cytologists/cytotechnologists (CTs) and the ratio of thyroid AUS interpretations by cytopathologists (CPs). These were formed into colored graphs that showcase individual results in established, color-coded laboratory "goal," "borderline," and "attention" zones based on published reference benchmarks. A representation of the results distribution for the entire laboratory was also developed. RESULTS We successfully created a web-based test application that presents interactive dashboards with different interfaces for the CT, CP, and laboratory management (https://drkvcsstvn-dashboards.hf.space/app). The user can choose to view the desired quality metric, year, and the anonymized CT or CP, with an additional automatically generated written report of results. CONCLUSIONS Python programming proved to be an effective toolkit to ensure high-level data processing in a modular and reproducible way to create a personalized, laboratory specific cytology dashboard.
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Hosking K, Binks P, De Santis T, Wilson PM, Gurruwiwi GG, Bukulatjpi SM, Vintour-Cesar E, McKinnon M, Nihill P, Fernandes TA, Greenwood-Smith B, Batey R, Ross C, Tong SY, Stewart G, Marshall C, Gargan C, Manchikanti P, Fuller K, Tate-Baker J, Stewart S, Cowie B, Allard N, MacLachlan JH, Qama A, Boettiger D, Davis JS, Connors C, Davies J. Evaluating a novel model of hepatitis B care, Hep B PAST, in the Northern Territory of Australia: results from a prospective, population-based study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 48:101116. [PMID: 38966601 PMCID: PMC11222935 DOI: 10.1016/j.lanwpc.2024.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/02/2024] [Accepted: 05/28/2024] [Indexed: 07/06/2024]
Abstract
Background The Northern Territory (NT) has the highest prevalence of chronic hepatitis B (CHB) in Australia. The Hep B PAST program aims to improve health outcomes for people living with CHB. Methods This mixed methods study involves First Nations peoples living in the NT. We used participatory action research principles across three steps: 1. Foundation step: establishing hepatitis B virus (HBV) status and linkage to care; 2. Capacity building: training the health workforce; 3. Supported transition to primary healthcare: implementation of the "Hub and Spoke" model and in-language resources. Analysis occurred at three time points: 1. Pre-Hep B PAST (2018); 2. Foundation step (2020); and 3. Completion of Hep B PAST (2023). Evaluation focuses on four key indicators, the number of people: 1) with documented HBV status; 2) diagnosed with CHB; 3) receiving care; and 4) receiving treatment. Findings Hep B PAST (2018-23) reached 40,555 people. HBV status was documented in 11% (1192/10,853), 79.2% (26,075/32,915) and 90.8% (28,675/31,588) of people at pre-Hep B PAST, foundation step, and completion respectively. An estimated 99.9% (821/822) of people were diagnosed, 86.3% (709/822) engaged in care, and 24.1% (198/822) on antiviral treatment at completion. CHB prevalence in the study population is 2.6%, decreasing from 6.1% to 0.4% in the pre- and post-vaccination cohorts. Interpretation Hep B PAST is an effective model of care. Partner health services are exceeding elimination targets. This model could enable other countries to enhance the cascade of care and work towards eliminating HBV. Funding National Health and Medical Research Council.
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Affiliation(s)
- Kelly Hosking
- Northern Territory Health, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Paula Binks
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | | | - George Garambaka Gurruwiwi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Emily Vintour-Cesar
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Melita McKinnon
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Peter Nihill
- Northern Territory Health, Northern Territory, Australia
| | | | | | - Robert Batey
- Northern Territory Health, Northern Territory, Australia
| | - Cheryl Ross
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Steven Y.C. Tong
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | | | - Catherine Marshall
- Northern Territory Health, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Prashanti Manchikanti
- Miwatj Aboriginal Health Corporation, Nhulunbuy, East Arnhem Land, Northern Territory, Australia
| | - Karen Fuller
- Katherine West Health Board, Katherine, Northern Territory, Australia
| | | | - Sami Stewart
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, NSW, Australia
| | - Benjamin Cowie
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Parkville, Australia
| | - Nicole Allard
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Parkville, Australia
| | - Jennifer H. MacLachlan
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Parkville, Australia
| | - Ashleigh Qama
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Victoria, Australia
| | - David Boettiger
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Kirby Institute, UNSW Sydney, NSW, Australia
| | - Joshua S. Davis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- School of Medicine and Public Health, University of Newcastle, NSW, Australia
| | | | - Jane Davies
- Northern Territory Health, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Hep B PAST partnership
- Northern Territory Health, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Miwatj Aboriginal Health Corporation, Nhulunbuy, East Arnhem Land, Northern Territory, Australia
- Katherine West Health Board, Katherine, Northern Territory, Australia
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, NSW, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Parkville, Australia
- Kirby Institute, UNSW Sydney, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, NSW, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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Dufour E, Duhoux A. How to Design Effective Audit and Feedback Interventions With Nurses: A Set of Hypotheses Based on Qualitative and Quantitative Evidence. J Nurs Adm 2024; 54:427-432. [PMID: 39016612 DOI: 10.1097/nna.0000000000001452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To propose practical hypotheses on audit and feedback that support the effectiveness with nurses. BACKGROUND Audit and feedback interventions have been mainly studied with physicians; however, the processes have been practiced by nurses for years. Nurses' response may differ from that of physicians and other healthcare disciplines because of their roles, power, and the configuration of nursing activities. METHODS A comparative analysis of the Clinical Performance Feedback Intervention Theory was conducted using nursing-specific empirical data from: 1) a mixed-methods systematic review and 2) a pilot study of audit and feedback with a team of primary care nurses. RESULTS Researchers hypothesize that audit and feedback interventions are more effective when: 1) feedback emphasizes how it relates to the relational aspect of nursing; 2) indicators are measured and reported at team level; and 3) feedback is provided in a way that highlights benefits to nurses' practice, such as the potential to reduce workload. CONCLUSION These proposed hypotheses provide concrete guidance to researchers and managers for an effective use of audit and feedback as a quality improvement strategy with nurses.
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Affiliation(s)
- Emilie Dufour
- Author Affiliations: Assistant Professor (Dr Dufour) and Associate Professor (Dr Duhoux), Faculty of Nursing, Université de Montréal, Montréal, Canada
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Mukherjee M, Okusi C, Jamie G, Byford R, Ferreira F, Fletcher M, de Lusignan S, Sheikh A. Deploying an asthma dashboard to support quality improvement across a nationally representative sentinel network of 7.6 million people in England. NPJ Prim Care Respir Med 2024; 34:18. [PMID: 38951547 PMCID: PMC11217285 DOI: 10.1038/s41533-024-00377-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/21/2024] [Indexed: 07/03/2024] Open
Abstract
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.
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Grants
- This work is carried out with the support of BREATHE - The Health Data Research Hub for Respiratory Health [MC_PC_19004] in partnership with Oxford-RCGP Clinical Informatics Digital Hub (ORCHID), a trusted research environment. BREATHE is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and delivered through Health Data Research UK. Health Data Research UK is funded by UK Research and Innovation, the Medical Research Council, the British Heart Foundation, Cancer Research UK, the National Institute for Health and Care Research, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, Health and Care Research Wales, Health and Social Care Research and Development Division (Public Health Agency, Northern Ireland), Chief Scientist Office of the Scottish Government Health and Social Care Directorates. This work was also funded by The Health Data Research UK, reference EDIN1 and Asthma + Lung UK, reference AUK-AC-2018-01.
- No Relevant Funding
- Health Data Research UK, grant number EDIN1
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Affiliation(s)
- Mome Mukherjee
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK.
- HDR UK BREATHE Respiratory Data Hub, Usher Institute, The University of Edinburgh, Edinburgh, UK.
- HDR UK Better Care, Usher Institute, The University of Edinburgh, Edinburgh, UK.
| | - Cecilia Okusi
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gavin Jamie
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rachel Byford
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Filipa Ferreira
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monica Fletcher
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
- HDR UK BREATHE Respiratory Data Hub, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Simon de Lusignan
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
- HDR UK BREATHE Respiratory Data Hub, Usher Institute, The University of Edinburgh, Edinburgh, UK
- HDR UK Better Care, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Bartels S, Levison JH, Trieu HD, Wilson A, Krane D, Cheng D, Xie H, Donelan K, Bird B, Shellenberger K, Cella E, Oreskovic NM, Irwin K, Aschbrenner K, Fathi A, Gamse S, Holland S, Wolfe J, Chau C, Adejinmi A, Langlois J, Reichman JL, Iezzoni LI, Skotko BG. Tailored vs. General COVID-19 prevention for adults with mental disabilities residing in group homes: a randomized controlled effectiveness-implementation trial. BMC Public Health 2024; 24:1705. [PMID: 38926810 PMCID: PMC11201789 DOI: 10.1186/s12889-024-18835-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/13/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND People with serious mental illness (SMI) and people with intellectual disabilities/developmental disabilities (ID/DD) are at higher risk for COVID-19 and more severe outcomes. We compare a tailored versus general best practice COVID-19 prevention program in group homes (GHs) for people with SMI or ID/DD in Massachusetts (MA). METHODS A hybrid effectiveness-implementation cluster randomized control trial compared a four-component implementation strategy (Tailored Best Practices: TBP) to dissemination of standard prevention guidelines (General Best-Practices: GBP) in GHs across six MA behavioral health agencies. GBP consisted of standard best practices for preventing COVID-19. TBP included GBP plus four components including: (1) trusted-messenger peer testimonials on benefits of vaccination; (2) motivational interviewing; (3) interactive education on preventive practices; and (4) fidelity feedback dashboards for GHs. Primary implementation outcomes were full COVID-19 vaccination rates (baseline: 1/1/2021-3/31/2021) and fidelity scores (baseline: 5/1/21-7/30/21), at 3-month intervals to 15-month follow-up until October 2022. The primary effectiveness outcome was COVID-19 infection (baseline: 1/1/2021-3/31/2021), measured every 3 months to 15-month follow-up. Cumulative incidence of vaccinations were estimated using Kaplan-Meier curves. Cox frailty models evaluate differences in vaccination uptake and secondary outcomes. Linear mixed models (LMMs) and Poisson generalized linear mixed models (GLMMs) were used to evaluate differences in fidelity scores and incidence of COVID-19 infections. RESULTS GHs (n=415) were randomized to TBP (n=208) and GBP (n=207) including 3,836 residents (1,041 ID/DD; 2,795 SMI) and 5,538 staff. No differences were found in fidelity scores or COVID-19 incidence rates between TBP and GBP, however TBP had greater acceptability, appropriateness, and feasibility. No overall differences in vaccination rates were found between TBP and GBP. However, among unvaccinated group home residents with mental disabilities, non-White residents achieved full vaccination status at double the rate for TBP (28.6%) compared to GBP (14.4%) at 15 months. Additionally, the impact of TBP on vaccine uptake was over two-times greater for non-White residents compared to non-Hispanic White residents (ratio of HR for TBP between non-White and non-Hispanic White: 2.28, p = 0.03). CONCLUSION Tailored COVID-19 prevention strategies are beneficial as a feasible and acceptable implementation strategy with the potential to reduce disparities in vaccine acceptance among the subgroup of non-White individuals with mental disabilities. TRIAL REGISTRATION ClinicalTrials.gov, NCT04726371, 27/01/2021. https://clinicaltrials.gov/study/NCT04726371 .
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Affiliation(s)
- Stephen Bartels
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA.
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Gray 7-730, Boston, MA, 02114, USA.
| | - Julie H Levison
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Gray 7-730, Boston, MA, 02114, USA
| | - Hao D Trieu
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
| | - Anna Wilson
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
| | - David Krane
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
| | - David Cheng
- Department of Biostatistics, Harvard Medical School, Massachusetts General Hospital, 50 Staniford Street, Suite 560, Boston, MA, 02114, USA
| | - Haiyi Xie
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Third Floor, HB 7261, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Karen Donelan
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
| | - Bruce Bird
- Vinfen Corporation, 950 Cambridge Street, Cambridge, MA, 02141, USA
| | | | - Elizabeth Cella
- Vinfen Corporation, 950 Cambridge Street, Cambridge, MA, 02141, USA
| | - Nicolas M Oreskovic
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Gray 7-730, Boston, MA, 02114, USA
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, 125 Nashua Street, Suite 821, Boston, MA, 02114, USA
- Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02214, USA
| | - Kelly Irwin
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kelly Aschbrenner
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Ahmed Fathi
- Vinfen Corporation, 950 Cambridge Street, Cambridge, MA, 02141, USA
| | - Stefanie Gamse
- Vinfen Corporation, 950 Cambridge Street, Cambridge, MA, 02141, USA
| | - Sibyl Holland
- Vinfen Corporation, 950 Cambridge Street, Cambridge, MA, 02141, USA
| | - Jessica Wolfe
- Vinfen Corporation, 950 Cambridge Street, Cambridge, MA, 02141, USA
| | - Cindy Chau
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
| | - Adeola Adejinmi
- Bay Cove Human Services, 66 Canal Street, Boston, MA, 02114, USA
| | | | | | - Lisa I Iezzoni
- Mongan Institute, Massachusetts General Hospital,, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
| | - Brian G Skotko
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, 125 Nashua Street, Suite 821, Boston, MA, 02114, USA
- Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02214, USA
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Hunter B, Davidson S, Lumsden N, Chima S, Gutierrez JM, Emery J, Nelson C, Manski-Nankervis JA. Optimising a clinical decision support tool to improve chronic kidney disease management in general practice. BMC PRIMARY CARE 2024; 25:220. [PMID: 38898462 PMCID: PMC11186183 DOI: 10.1186/s12875-024-02470-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Early identification and treatment of chronic disease is associated with better clinical outcomes, lower costs, and reduced hospitalisation. Primary care is ideally placed to identify patients at risk of, or in the early stages of, chronic disease and to implement prevention and early intervention measures. This paper evaluates the implementation of a technological intervention called Future Health Today that integrates with general practice EMRs to (1) identify patients at-risk of, or with undiagnosed or untreated, chronic kidney disease (CKD), and (2) provide guideline concordant recommendations for patient care. The evaluation aimed to identify the barriers and facilitators to successful implementation. METHODS Future Health Today was implemented in 12 general practices in Victoria, Australia. Fifty-two interviews with 30 practice staff were undertaken between July 2020 and April 2021. Practice characteristics were collected directly from practices via survey. Data were analysed using inductive and deductive qualitative analysis strategies, using Clinical Performance - Feedback Intervention Theory (CP-FIT) for theoretical guidance. RESULTS Future Health Today was acceptable, user friendly and useful to general practice staff, and supported clinical performance improvement in the identification and management of chronic kidney disease. CP-FIT variables supporting use of FHT included the simplicity of design and delivery of actionable feedback via FHT, good fit within existing workflow, strong engagement with practices and positive attitudes toward FHT. Context variables provided the main barriers to use and were largely situated in the external context of practices (including pressures arising from the COVID-19 pandemic) and technical glitches impacting installation and early use. Participants primarily utilised the point of care prompt rather than the patient management dashboard due to its continued presence, and immediacy and relevance of the recommendations on the prompt, suggesting mechanisms of compatibility, complexity, actionability and credibility influenced use. Most practices continued using FHT after the evaluation phase was complete. CONCLUSIONS This study demonstrates that FHT is a useful and acceptable software platform that provides direct support to general practice in identifying and managing patients with CKD. Further research is underway to explore the effectiveness of FHT, and to expand the conditions on the platform.
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Affiliation(s)
- Barbara Hunter
- Department of General Practice and Primary Care, University of Melbourne, Melbourne, Australia.
| | - Sandra Davidson
- Department of General Practice and Primary Care, University of Melbourne, Melbourne, Australia
| | - Natalie Lumsden
- Department of General Practice and Primary Care, University of Melbourne, Melbourne, Australia
- Western Health Chronic Disease Alliance, Western Health Melbourne, Melbourne, Australia
| | - Sophie Chima
- Department of General Practice and Primary Care, University of Melbourne, Melbourne, Australia
| | - Javiera Martinez Gutierrez
- Department of General Practice and Primary Care, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
- Family Medicine Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jon Emery
- Department of General Practice and Primary Care, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
- The Primary Care Unit, University of Cambridge, Cambridge, UK
| | - Craig Nelson
- Western Health Chronic Disease Alliance, Western Health Melbourne, Melbourne, Australia
- Department of Medicine - Western Health, University of Melbourne, Melbourne, Australia
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Landis-Lewis Z, Andrews CA, Gross CA, Friedman CP, Shah NJ. Exploring Anesthesia Provider Preferences for Precision Feedback: Preference Elicitation Study. JMIR MEDICAL EDUCATION 2024; 10:e54071. [PMID: 38889065 PMCID: PMC11185285 DOI: 10.2196/54071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/05/2024] [Accepted: 04/26/2024] [Indexed: 06/20/2024]
Abstract
Background Health care professionals must learn continuously as a core part of their work. As the rate of knowledge production in biomedicine increases, better support for health care professionals' continuous learning is needed. In health systems, feedback is pervasive and is widely considered to be essential for learning that drives improvement. Clinical quality dashboards are one widely deployed approach to delivering feedback, but engagement with these systems is commonly low, reflecting a limited understanding of how to improve the effectiveness of feedback about health care. When coaches and facilitators deliver feedback for improving performance, they aim to be responsive to the recipient's motivations, information needs, and preferences. However, such functionality is largely missing from dashboards and feedback reports. Precision feedback is the delivery of high-value, motivating performance information that is prioritized based on its motivational potential for a specific recipient, including their needs and preferences. Anesthesia care offers a clinical domain with high-quality performance data and an abundance of evidence-based quality metrics. Objective The objective of this study is to explore anesthesia provider preferences for precision feedback. Methods We developed a test set of precision feedback messages with balanced characteristics across 4 performance scenarios. We created an experimental design to expose participants to contrasting message versions. We recruited anesthesia providers and elicited their preferences through analysis of the content of preferred messages. Participants additionally rated their perceived benefit of preferred messages to clinical practice on a 5-point Likert scale. Results We elicited preferences and feedback message benefit ratings from 35 participants. Preferences were diverse across participants but largely consistent within participants. Participants' preferences were consistent for message temporality (α=.85) and display format (α=.80). Ratings of participants' perceived benefit to clinical practice of preferred messages were high (mean rating 4.27, SD 0.77). Conclusions Health care professionals exhibited diverse yet internally consistent preferences for precision feedback across a set of performance scenarios, while also giving messages high ratings of perceived benefit. A "one-size-fits-most approach" to performance feedback delivery would not appear to satisfy these preferences. Precision feedback systems may hold potential to improve support for health care professionals' continuous learning by accommodating feedback preferences.
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Affiliation(s)
- Zach Landis-Lewis
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Chris A Andrews
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Colin A Gross
- Biostatistics Department, University of Michigan, Ann Arbor, MI, United States
| | - Charles P Friedman
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Nirav J Shah
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
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17
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Park KU, Padamsee TJ, Birken SA, Lee S, Niles K, Blair SL, Grignol V, Dickson-Witmer D, Nowell K, Neuman H, King T, Mittendorf E, Paskett ED, Brindle M. Factors Influencing Implementation of the Commission on Cancer's Breast Synoptic Operative Report (Alliance A20_Pilot9). Ann Surg Oncol 2024:10.1245/s10434-024-15515-2. [PMID: 38862840 DOI: 10.1245/s10434-024-15515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The technical aspects of cancer surgery have a significant impact on patient outcomes. To monitor surgical quality, in 2020, the Commission on Cancer (CoC) revised its accreditation standards for cancer surgery and introduced the synoptic operative reports (SORs). The standardization of SORs holds promise, but successful implementation requires strategies to address key implementation barriers. This study aimed to identify the barriers and facilitators to implementing breast SOR within diverse CoC-accredited programs. METHODS In-depth semi-structured interviews were conducted with 31 health care professionals across diverse CoC-accredited sites. The study used two comprehensive implementation frameworks to guide data collection and analysis. RESULTS Successful SOR implementation was impeded by disrupted workflows, surgeon resistance to change, low prioritization of resources, and poor flow of information despite CoC's positive reputation. Participants often lacked understanding of the requirements and timeline for breast SOR and were heavily influenced by prior experiences with templates and SOR champion relationships. The perceived lack of monetary benefits (to obtaining CoC accreditation) together with the significant information technology (IT) resource requirements tempered some of the enthusiasm. Additionally, resource constraints and the redirection of personnel during the COVID-19 pandemic were noted as hurdles. CONCLUSIONS Surgeon behavior and workflow change, IT and personnel resources, and communication and networking strategies influenced SOR implementation. During early implementation and the implementation planning phase, the primary focus was on achieving buy-in and initiating successful roll-out rather than effective use or sustainment. These findings have implications for enhancing standardization of surgical cancer care and guidance of future strategies to optimize implementation of CoC accreditation standards.
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Affiliation(s)
- Ko Un Park
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber/ Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Tasleem J Padamsee
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Sarah A Birken
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Sandy Lee
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Kaleigh Niles
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Sarah L Blair
- University of California San Diego, La Jolla, CA, USA
| | - Valerie Grignol
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | | | - Kerri Nowell
- Physicians' Clinic of Iowa, Cedar Rapids, IA, USA
| | - Heather Neuman
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Tari King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/ Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/ Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Electra D Paskett
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Mary Brindle
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Canada
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18
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Johnson G, Singh H, Helewa RM, Sibley KM, Reynolds KA, El-Kefraoui C, Doupe MB. Gastroenterologist and surgeon perceptions of recommendations for optimal endoscopic localization of colorectal neoplasms. Sci Rep 2024; 14:13157. [PMID: 38849393 PMCID: PMC11161634 DOI: 10.1038/s41598-024-63753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/31/2024] [Indexed: 06/09/2024] Open
Abstract
National consensus recommendations have recently been developed to standardize colorectal tumour localization and documentation during colonoscopy. In this qualitative semi-structured interview study, we identified and contrast the perceived barriers and facilitators to using these new recommendations according to gastroenterologists and surgeons in a large central Canadian city. Interviews were analyzed according to the Consolidated Framework for Implementation Research (CFIR) through directed content analysis. Solutions were categorized using the Expert Recommendations for Implementing Change (ERIC) framework. Eleven gastroenterologists and ten surgeons participated. Both specialty groups felt that the new recommendations were clearly written, adequately addressed current care practice tensions, and offered a relative advantage versus existing practices. The new recommendations appeared appropriately complex, applicable to most participants, and could be trialed and adapted prior to full implementation. Major barriers included a lack of relevant external or internal organizational incentives, non-existing formal feedback processes, and a lack of individual familiarity with the evidence behind some recommendations. With application of the ERIC framework, common barriers could be addressed through accessing new funding, altering incentive structures, changing record systems, educational interventions, identifying champions, promoting adaptability, and employing audit/feedback processes. Future research is needed to test strategies for feasibility and effectiveness.
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Affiliation(s)
- Garrett Johnson
- Department of Surgery, Section of General Surgery, University of Manitoba, AE101-820 Sherbrook St, Winnipeg, MB, R3A 1R9, Canada.
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada.
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, and CancerCare Manitoba Research Institute, Winnipeg, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Ramzi M Helewa
- Department of Surgery, Section of General Surgery, University of Manitoba, AE101-820 Sherbrook St, Winnipeg, MB, R3A 1R9, Canada
| | - Kathryn M Sibley
- Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- George and Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | - Kristin A Reynolds
- Departments of Psychology and Psychiatry, University of Manitoba, Winnipeg, Canada
| | - Charbel El-Kefraoui
- Department of Surgery, Section of General Surgery, University of Manitoba, AE101-820 Sherbrook St, Winnipeg, MB, R3A 1R9, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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19
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Schwartz KL, Shuldiner J, Langford BJ, Brown KA, Schultz SE, Leung V, Daneman N, Tadrous M, Witteman HO, Garber G, Grimshaw JM, Leis JA, Presseau J, Silverman MS, Taljaard M, Gomes T, Lacroix M, Brehaut J, Thavorn K, Gushue S, Friedman L, Zwarenstein M, Ivers N. Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial. BMJ 2024; 385:e079329. [PMID: 38839101 PMCID: PMC11151833 DOI: 10.1136/bmj-2024-079329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms. DESIGN Pragmatic, factorial randomised controlled trial. SETTING Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial. INTERVENTION A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics. MAIN OUTCOME MEASURES Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression. RESULTS 5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)). CONCLUSIONS Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care. TRIAL REGISTRATION ClinicalTrials.gov NCT04594200.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Bradley J Langford
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Kevin A Brown
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada
- Vitam Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Gary Garber
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
| | - Jeremy M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Jerome A Leis
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Tara Gomes
- ICES, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Meagan Lacroix
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | | | - Merrick Zwarenstein
- Departments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Noah Ivers
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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20
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Forgiarini A, Deroma L, Buttussi F, Zangrando N, Licata S, Valent F, Chittaro L, Di Chiara A. Introducing Virtual Reality in a STEMI Coronary Syndrome Course: Qualitative Evaluation with Nurses and Doctors. CYBERPSYCHOLOGY, BEHAVIOR AND SOCIAL NETWORKING 2024; 27:387-398. [PMID: 38527251 DOI: 10.1089/cyber.2023.0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
In the increasing number of medical education topics taught with virtual reality (VR), the prehospital management of ST-segment elevation myocardial infarction (STEMI) had not been considered. This article proposes an implemented VR system for STEMI training and introduces it in an institutional course addressed to emergency nurses and case manager (CM) doctors. The system comprises three different applications to, respectively, allow (a) the course instructor to control the conditions of the virtual patient, (b) the CM to communicate with the nurse in the virtual field and receive from him/her the patient's parameters and electrocardiogram, and (c) the nurse to interact with the patient in the immersive VR scenario. We enrolled 17 course participants to collect their perceptions and opinions through a semistructured interview. The thematic analysis showed the system was appreciated (n = 17) and described as engaging (n = 4), challenging (n = 5), useful to improve self-confidence (n = 4), innovative (n = 5), and promising for training courses (n = 10). Realism was also appreciated (n = 13), although with some drawbacks (e.g., oversimplification; n = 5). Overall, participants described the course as an opportunity to share opinions (n = 8) and highlight issues (n = 4) and found it useful for novices (n = 5) and, as a refresh, for experienced personnel (n = 6). Some participants suggested improvements in the scenarios' type (n = 5) and variability (n = 5). Although most participants did not report usage difficulties with the VR system (n = 13), many described the need to get familiar with it (n = 13) and the specific gestures it requires (n = 10). Three suffered from cybersickness.
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Affiliation(s)
- Alessandro Forgiarini
- Human-Computer Interaction Laboratory, Department of Mathematics, Computer Science and Physics, University of Udine, Udine, Italy
- Hygiene and Clinical Epidemiology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Laura Deroma
- Hygiene and Public Health Unit, Department of Prevention, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Fabio Buttussi
- Human-Computer Interaction Laboratory, Department of Mathematics, Computer Science and Physics, University of Udine, Udine, Italy
| | - Nicola Zangrando
- Hygiene and Clinical Epidemiology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Sabrina Licata
- Hygiene and Clinical Epidemiology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Francesca Valent
- Hygiene and Clinical Epidemiology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Luca Chittaro
- Human-Computer Interaction Laboratory, Department of Mathematics, Computer Science and Physics, University of Udine, Udine, Italy
| | - Antonio Di Chiara
- Cardiology Tolmezzo, San Daniele-Tolmezzo Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
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21
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Asemu YM, Yigzaw T, Desta FA, Scheele F, van den Akker T. Does higher performance in a national licensing examination predict better quality of care? A longitudinal observational study of Ethiopian anesthetists. BMC Anesthesiol 2024; 24:188. [PMID: 38802780 PMCID: PMC11129401 DOI: 10.1186/s12871-024-02575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Ethiopia made a national licensing examination (NLE) for associate clinician anesthetists a requirement for entry into the practice workforce. However, there is limited empirical evidence on whether the NLE scores of associate clinicians predict the quality of health care they provide in low-income countries. This study aimed to assess the association between anesthetists' NLE scores and three selected quality of patient care indicators. METHODS A multicenter longitudinal observational study was conducted between January 8 and February 7, 2023, to collect quality of care (QoC) data on surgical patients attended by anesthetists (n = 56) who had taken the Ethiopian anesthetist NLE since 2019. The three QoC indicators were standards for safe anesthesia practice, critical incidents, and patient satisfaction. The medical records of 991 patients were reviewed to determine the standards for safe anesthesia practice and critical incidents. A total of 400 patients responded to the patient satisfaction survey. Multivariable regressions were employed to determine whether the anesthetist NLE score predicted QoC indicators. RESULTS The mean percentage of safe anesthesia practice standards met was 69.14%, and the mean satisfaction score was 85.22%. There were 1,120 critical incidents among 911 patients, with three out of five experiencing at least one. After controlling for patient, anesthetist, facility, and clinical care-related confounding variables, the NLE score predicted the occurrence of critical incidents. For every 1% point increase in the total NLE score, the odds of developing one or more critical incidents decreased by 18% (aOR = 0.82; 95% CI = 0.70 = 0.96; p = 0.016). No statistically significant associations existed between the other two QoC indicators and NLE scores. CONCLUSION The NLE score had an inverse relationship with the occurrence of critical incidents, supporting the validity of the examination in assessing graduates' ability to provide safe and effective care. The lack of an association with the other two QoC indicators requires further investigation. Our findings may help improve education quality and the impact of NLEs in Ethiopia and beyond.
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Affiliation(s)
- Yohannes Molla Asemu
- Health Workforce Improvement Program, Jhpiego, an affiliate of Johns Hopkins University, Ethiopia country office, Addis Ababa, Ethiopia.
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Tegbar Yigzaw
- Health Workforce Improvement Program, Jhpiego, an affiliate of Johns Hopkins University, Ethiopia country office, Addis Ababa, Ethiopia
| | - Firew Ayalew Desta
- Health Workforce Improvement Program, Jhpiego, an affiliate of Johns Hopkins University, Ethiopia country office, Addis Ababa, Ethiopia
| | - Fedde Scheele
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Obstetrics and Gynecology, OLVG Teaching Hospital, Amsterdam, the Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (AUMC), Amsterdam, the Netherlands
| | - Thomas van den Akker
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
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22
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Salins N, Rao K, Damani A, Hughes S, Preston N. Paediatric oncologists' perspectives on Strategic solutions to develop Integrated Cancer Palliative Care: feedback intervention theory as an explanatory Framework. BMC Palliat Care 2024; 23:130. [PMID: 38778373 PMCID: PMC11112766 DOI: 10.1186/s12904-024-01462-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Globally, children with cancer often experience delays in palliative care referral or are infrequently referred. Therefore, we conducted a qualitative study to gain insight from paediatric oncologists into what enables or deters palliative care referral. Strategic solutions to develop integrated palliative care was a critical study theme. In this paper, we have explained and interpreted these strategic solutions through the lens of feedback intervention theory. METHODOLOGY The study findings were interpreted using Kumar's six-step approach that enabled systematic evaluation of a theory's appropriateness and alignment with the researcher's paradigm, methodology, and study findings. It also explained how theory informed analysis and elucidated challenges or the development of new models. The feedback intervention theory appraises the discrepancy between actual and desired goals and provides feedback to improve it. RESULTS Strategic solutions generated from the study findings were coherent with the aspects elucidated in theory, like coping mechanisms, levels of feedback hierarchy, and factors determining the effect of the feedback intervention on performance. Paediatric oncologists suggested integrating palliative care providers in the team innocuously, improving communication between teams, relabelling palliative care as symptom control, and working with a skilled and accessible palliative care team. The paper proposes an infinite loop model developed from the study, which has the potential to foster integrated palliative care through excellent collaboration and continuous feedback. CONCLUSION Applying feedback intervention theory can bridge the gap between actual and desired practice for integrated cancer palliative care in paediatric oncology.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Krithika Rao
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Sean Hughes
- Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, United Kingdom
| | - Nancy Preston
- Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, United Kingdom
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Ward MJ, Matheny ME, Rubenstein MD, Bonnet K, Dagostino C, Schlundt DG, Anders S, Reese T, Mixon AS. Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration. BMC Health Serv Res 2024; 24:640. [PMID: 38760660 PMCID: PMC11102113 DOI: 10.1186/s12913-024-11082-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.
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Affiliation(s)
- Michael J Ward
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA.
- Medicine Service, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael E Matheny
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa D Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Chloe Dagostino
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Shilo Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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24
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Pagano E, Pellegrino L, Robella M, Castiglione A, Brunetti F, Giacometti L, Rolfo M, Rizzo A, Palmisano S, Meineri M, Bachini I, Morino M, Allaix ME, Mellano A, Massucco P, Bellomo P, Polastri R, Ciccone G, Borghi F. Implementation of an enhanced recovery after surgery protocol for colorectal cancer in a regional hospital network supported by audit and feedback: a stepped wedge, cluster randomised trial. BMJ Qual Saf 2024; 33:363-374. [PMID: 38423752 PMCID: PMC11103294 DOI: 10.1136/bmjqs-2023-016594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention. METHODS A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items. RESULTS Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of -0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68). CONCLUSION Implementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications. Trial registration number NCT04037787.
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Affiliation(s)
- Eva Pagano
- Unit of Clinical Epidemiology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luca Pellegrino
- Surgical Oncology Department, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Torino, Italy
| | - Manuela Robella
- Surgical Oncology Department, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Torino, Italy
| | - Anna Castiglione
- Unit of Clinical Epidemiology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesco Brunetti
- Unit of Clinical Epidemiology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Lisa Giacometti
- Unit of Clinical Epidemiology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Alessio Rizzo
- General Surgery and Oncology Unit, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Sarah Palmisano
- Anaesthesia and Intensive Care Unit, S Croce and Carle Cuneo Hospital Districts, Cuneo, Italy
| | - Maurizio Meineri
- Anaesthesia and Intensive Care Unit, S Croce and Carle Cuneo Hospital Districts, Cuneo, Italy
| | - Ilaria Bachini
- Clinical Nutrition and Dietetics Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Mario Morino
- Digestive and Oncological Surgery, Center for Minimal Invasive Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Ettore Allaix
- Digestive and Oncological Surgery, Center for Minimal Invasive Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alfredo Mellano
- Surgical Oncology Department, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Torino, Italy
| | - Paolo Massucco
- General Surgery and Oncology Unit, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Paola Bellomo
- General Surgery, Presidio Sanitario Gradenigo, Torino, Italy
| | - Roberto Polastri
- Department of Surgery, General Surgery Unit, Hospital of Biella, Ponderano, Biella, Italy
| | - Giovannino Ciccone
- Unit of Clinical Epidemiology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Felice Borghi
- Surgical Oncology Department, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Torino, Italy
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Teede H, Cadilhac DA, Purvis T, Kilkenny MF, Campbell BCV, English C, Johnson A, Callander E, Grimley RS, Levi C, Middleton S, Hill K, Enticott J. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 2024; 22:198. [PMID: 38750449 PMCID: PMC11094907 DOI: 10.1186/s12916-024-03416-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 04/30/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit. MAIN TEXT Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement. CONCLUSIONS The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.
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Affiliation(s)
- Helena Teede
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia.
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia.
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia.
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia.
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Bruce C V Campbell
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Coralie English
- School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia
| | - Alison Johnson
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia
| | - Emily Callander
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia
| | - Rohan S Grimley
- School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia
- Clinical Excellence Division, Queensland Health, Brisbane, Australia
| | - Christopher Levi
- John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia
| | - Sandy Middleton
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
- Nursing Research Institute, St Vincent's Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia
| | - Kelvin Hill
- Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia
| | - Joanne Enticott
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia
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Bishay AE, Hughes NC, Zargari M, Paulo DL, Bishay S, Lyons AT, Morkos MN, Ball TJ, Englot DJ, Bick SK. Disparities in Access to Deep Brain Stimulation for Parkinson's Disease and Proposed Interventions: A Literature Review. Stereotact Funct Neurosurg 2024; 102:179-194. [PMID: 38697047 DOI: 10.1159/000538748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/28/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Deep brain stimulation (DBS) is an effective therapy for Parkinson's disease (PD), but disparities exist in access to DBS along gender, racial, and socioeconomic lines. SUMMARY Women are underrepresented in clinical trials and less likely to undergo DBS compared to their male counterparts. Racial and ethnic minorities are also less likely to undergo DBS procedures, even when controlling for disease severity and other demographic factors. These disparities can have significant impacts on patients' access to care, quality of life, and ability to manage their debilitating movement disorders. KEY MESSAGES Addressing these disparities requires increasing patient awareness and education, minimizing barriers to equitable access, and implementing diversity and inclusion initiatives within the healthcare system. In this systematic review, we first review literature discussing gender, racial, and socioeconomic disparities in DBS access and then propose several patient, provider, community, and national-level interventions to improve DBS access for all populations.
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Affiliation(s)
- Anthony E Bishay
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA,
| | - Natasha C Hughes
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michael Zargari
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Danika L Paulo
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven Bishay
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Mariam N Morkos
- Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | - Tyler J Ball
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Sarah K Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Verdini NP, Gelblum DY, Vertosick EA, Ostroff JS, Vickers AJ, Gomez DR, Gillespie EF. Evaluating a Physician Audit and Feedback Intervention to Increase Clinical Trial Enrollment in Radiation Oncology in a Multisite Tertiary Cancer Center: A Randomized Study. Int J Radiat Oncol Biol Phys 2024; 119:11-16. [PMID: 37769853 DOI: 10.1016/j.ijrobp.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE Clinical trial participation continues to be low, slowing new cancer therapy development. Few strategies have been prospectively tested to address barriers to enrollment. We investigated the effectiveness of a physician audit and feedback report to improve clinical trial enrollment. METHODS AND MATERIALS We conducted a randomized quality improvement study among radiation oncologists at a multisite tertiary cancer network. Physicians in the intervention group received quarterly audit and feedback reports comparing the physician's trial enrollments with those of their peers. The primary outcome was trial enrollments. RESULTS Among physicians randomized to receive the feedback report (n = 30), the median proportion of patients enrolled during the study period increased to 6.1% (IQR, 2.6%-9.3%) from 3.2% (IQR, 1.1%-10%) at baseline. Among those not receiving the feedback report (n = 29), the median proportion of patients enrolled increased to 4.1% (IQR, 1.3%-7.6%) from 1.6% (IQR, 0%-4.1%) at baseline. There was a nonsignificant change in the proportion of enrollments associated with receiving the feedback report (-0.6%; 95% CI, -3.0% to 1.8%; P = .6). Notably, there was an interaction between baseline trial accrual and receipt of feedback reports (P = .005), with enrollment declining among high accruers. There was an increase in enrollment throughout the study, regardless of study group (P = .001). CONCLUSIONS In this study, a positive effect of physician audit and feedback on clinical trial enrollment was not observed. Future efforts should avoid disincentivizing high accruers and might consider pairing feedback with other patient- or physician-level strategies. The increase in trial enrollment in both groups over time highlights the importance of including a comparison group in quality improvement studies to reduce confounding from secular trends.
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Affiliation(s)
- Nicholas P Verdini
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily A Vertosick
- Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie S Ostroff
- Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J Vickers
- Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiation Oncology, University of Washington, Seattle, Washington.
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28
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Levy C, Kononowech J, Ersek M, Phibbs CS, Scott W, Sales A. Evaluating feedback reports to support documentation of veterans' care preferences in home based primary care. BMC Geriatr 2024; 24:389. [PMID: 38693502 PMCID: PMC11064362 DOI: 10.1186/s12877-024-04999-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/19/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND To evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented. METHODS We distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation. RESULTS LST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports. CONCLUSIONS Feedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.
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Affiliation(s)
- Cari Levy
- Denver-Seattle VA Center of Innovation for Value Driven & Veteran-Centric Care, Rocky Mountain Regional VA Medical Center at VA Eastern Colorado Health Care System, Aurora, CO, USA
- Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Mary Ersek
- Center for Health Equity and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Schools of Nursing and Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ciaran S Phibbs
- Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, CA, USA
| | - Winifred Scott
- Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Anne Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing, Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
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29
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Gillespie EF, Santos PMG, Curry M, Salz T, Chakraborty N, Caron M, Fuchs HE, Ledesma Vicioso N, Mathis N, Kumar R, O’Brien C, Patel S, Guttmann DM, Ostroff JS, Salner AL, Panoff JE, McIntosh AF, Pfister DG, Vaynrub M, Yang JT, Lipitz-Snyderman A. Implementation Strategies to Promote Short-Course Radiation for Bone Metastases. JAMA Netw Open 2024; 7:e2411717. [PMID: 38787561 PMCID: PMC11127116 DOI: 10.1001/jamanetworkopen.2024.11717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/11/2024] [Indexed: 05/25/2024] Open
Abstract
Importance For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings. Objective To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions). Design, Setting, and Participants This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023. Exposures Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians. Main Outcomes and Measures The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy. Results Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly. Conclusions and Relevance In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.
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Affiliation(s)
- Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, University of Washington School of Medicine, Fred Hutchinson Cancer Center, Seattle
| | - Patricia Mae G. Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Curry
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Talya Salz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nirjhar Chakraborty
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Caron
- Department of Strategic Partnerships, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah E. Fuchs
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nahomy Ledesma Vicioso
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noah Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rahul Kumar
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
| | - Connor O’Brien
- Department of Radiation Oncology, Hartford HealthCare Cancer Institute, Hartford, Connecticut
| | - Shivani Patel
- Department of Radiation Oncology, Lehigh Valley Cancer Institute, Allentown, Pennsylvania
| | - David M. Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie S. Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew L. Salner
- Department of Radiation Oncology, Hartford HealthCare Cancer Institute, Hartford, Connecticut
| | - Joseph E. Panoff
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
| | - Alyson F. McIntosh
- Department of Radiation Oncology, Lehigh Valley Cancer Institute, Allentown, Pennsylvania
| | - David G. Pfister
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, NYU School of Medicine, New York, New York
| | - Allison Lipitz-Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Hernes SS, Høiberg M, Gallefoss F, Thoresen C, Tjomsland O. Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme. BMJ Open Qual 2024; 13:e002649. [PMID: 38684346 PMCID: PMC11086486 DOI: 10.1136/bmjoq-2023-002649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/12/2024] [Indexed: 05/02/2024] Open
Abstract
Utilisation rates for healthcare services vary widely both within and between nations. Moreover, healthcare providers with insurance-based reimbursement systems observe an effect of social determinants of health on healthcare utilisation rates and outcomes. Even in countries with publicly funded universal healthcare such as Norway, utilisation rates for medical and surgical interventions vary between and within health regions and hospitals.Most interventions targeting overuse and high utilisation rates are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation. Recommendations regarding how to reduce this variation are often not very detailed or prominent.This paper describes a protocol for reducing the overuse of upper endoscopy in a Norwegian health region. The protocol uses a combination of digital tools and psychological methods targeting behavioural change in order to alter healthcare workers' approach to patient care.The aim of the planned intervention is to evaluate the effectiveness of a multifaceted set of interventions to reduce the overuse of upper endoscopy in patients under 45 years. A secondary aim is to evaluate the specific effect of the various parts of the intervention.
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Affiliation(s)
- Susanne Sorensen Hernes
- Department of Geriatrics and Internal medicine, Sorlandet Hospital Arendal, Kristiansand, Agder, Norway
- Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Mikkel Høiberg
- Department of Endocrinology, Sorlandet Hospital Arendal, Arendal, Norway
| | - Frode Gallefoss
- Department of Clinical Sciences, University of Bergen, Bergen, Norway
- Department of Pulmonology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | | | - Ole Tjomsland
- Director of Quality and Specialist Areas, South-Eastern Norway Regional Health Authority, Hamar, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Smeekens L, Verburg AC, Maas M, van Heerde R, van Kerkhof A, van der Wees PJ. Feasibility of a quality-improvement program based on routinely collected health outcomes in Dutch primary care physical therapist practice: a mixed-methods study. BMC Health Serv Res 2024; 24:509. [PMID: 38658939 PMCID: PMC11040789 DOI: 10.1186/s12913-024-10958-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND This study evaluates the feasibility of a nine-month advanced quality-improvement program aimed at enhancing the quality of care provided by primary care physical therapists in the Netherlands. The evaluation is based on routinely collected health outcomes of patients with nonspecific low back pain, assessing three feasibility domains: (1) appropriateness, feasibility, and acceptability for quality-improvement purposes; (2) impact on clinical performance; and (3) impact on learning and behavioral change. METHODS A mixed-methods quality-improvement study using a concurrent triangulation design was conducted in primary care physical therapist practice. Feedback reports on the processes and outcomes of care, peer assessment, and self-assessment were used in a Plan-Do-Study-Act cycle based on self-selected goals. The program's appropriateness, feasibility, and acceptability, as well as the impact on clinical performance, were evaluated using the Intervention Appropriate Measure, Feasibility Intervention Measure, Acceptability Intervention Measure (for these three measure, possible scores range from 4 to 20), and with a self-assessment of clinical performance (scored 0-10), respectively. The impact on learning and behavioral change was evaluated qualitatively with a directed content analysis. RESULTS Ten physical therapists from two practices participated in this study. They rated the program with a mean of 16.5 (SD 1.9) for appropriateness, 17.1 (SD 2.2) for feasibility, and 16.4 (SD 1.5) for acceptability. Participants gave their development in clinical performance a mean score of 6.7 (SD 1.8). Participants became aware of the potential value of using outcome data and gained insight into their own routines and motivations. They changed their data collection routines, implemented data in their routine practice, and explored the impact on their clinical behavior. CONCLUSIONS This explorative study demonstrated that a quality-improvement program, using health outcomes from a national registry, is judged to be feasible. IMPACT STATEMENT This study provides preliminary evidence on how physical therapists may use health outcomes to improve their quality, which can be further used in initiatives to improve outcome-based care in primary physical therapy.
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Affiliation(s)
- Lsf Smeekens
- Scientific Institute for Quality of Healthcare, Radboud university medical center, Kapittelweg 54, 6525 EP, Nijmegen, The Netherlands.
| | - A C Verburg
- Scientific Institute for Quality of Healthcare, Radboud university medical center, Kapittelweg 54, 6525 EP, Nijmegen, The Netherlands
| | - Mjm Maas
- Scientific Institute for Quality of Healthcare, Radboud university medical center, Kapittelweg 54, 6525 EP, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - R van Heerde
- Scientific Institute for Quality of Healthcare, Radboud university medical center, Kapittelweg 54, 6525 EP, Nijmegen, The Netherlands
| | - A van Kerkhof
- Leidsche Rijn Julius Gezondheidscentra, Utrecht, The Netherlands
| | - P J van der Wees
- Scientific Institute for Quality of Healthcare, Radboud university medical center, Kapittelweg 54, 6525 EP, Nijmegen, The Netherlands
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Zewde HK. Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis. BMC Pregnancy Childbirth 2024; 24:266. [PMID: 38605302 PMCID: PMC11010365 DOI: 10.1186/s12884-024-06482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital. METHODS An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention's effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the "itsa' command in STATA. RESULTS During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p < 0.001), delayed care (- 8.76; p < 0.001) and substandard care (- 5.58; p < 0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p < 0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p < 0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p < 0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope. CONCLUSIONS Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.
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Affiliation(s)
- Henos Kiflom Zewde
- Department of Family and Community Health, Ministry of Health Anseba Region Branch, Keren, Anseba, Eritrea.
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Hoffmann C, Avery K, Macefield R, Dvořák T, Snelgrove V, Blazeby J, Hopkins D, Hickey S, Gibbison B, Rooshenas L, Williams A, Aning J, Bekker HL, McNair AG. Usability of an Automated System for Real-Time Monitoring of Shared Decision-Making for Surgery: Mixed Methods Evaluation. JMIR Hum Factors 2024; 11:e46698. [PMID: 38598276 PMCID: PMC11043934 DOI: 10.2196/46698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 10/02/2023] [Accepted: 03/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Improving shared decision-making (SDM) for patients has become a health policy priority in many countries. Achieving high-quality SDM is particularly important for approximately 313 million surgical treatment decisions patients make globally every year. Large-scale monitoring of surgical patients' experience of SDM in real time is needed to identify the failings of SDM before surgery is performed. We developed a novel approach to automating real-time data collection using an electronic measurement system to address this. Examining usability will facilitate its optimization and wider implementation to inform interventions aimed at improving SDM. OBJECTIVE This study examined the usability of an electronic real-time measurement system to monitor surgical patients' experience of SDM. We aimed to evaluate the metrics and indicators relevant to system effectiveness, system efficiency, and user satisfaction. METHODS We performed a mixed methods usability evaluation using multiple participant cohorts. The measurement system was implemented in a large UK hospital to measure patients' experience of SDM electronically before surgery using 2 validated measures (CollaboRATE and SDM-Q-9). Quantitative data (collected between April 1 and December 31, 2021) provided measurement system metrics to assess system effectiveness and efficiency. We included adult patients booked for urgent and elective surgery across 7 specialties and excluded patients without the capacity to consent for medical procedures, those without access to an internet-enabled device, and those undergoing emergency or endoscopic procedures. Additional groups of service users (group 1: public members who had not engaged with the system; group 2: a subset of patients who completed the measurement system) completed user-testing sessions and semistructured interviews to assess system effectiveness and user satisfaction. We conducted quantitative data analysis using descriptive statistics and calculated the task completion rate and survey response rate (system effectiveness) as well as the task completion time, task efficiency, and relative efficiency (system efficiency). Qualitative thematic analysis identified indicators of and barriers to good usability (user satisfaction). RESULTS A total of 2254 completed surveys were returned to the measurement system. A total of 25 service users (group 1: n=9; group 2: n=16) participated in user-testing sessions and interviews. The task completion rate was high (169/171, 98.8%) and the survey response rate was good (2254/5794, 38.9%). The median task completion time was 3 (IQR 2-13) minutes, suggesting good system efficiency and effectiveness. The qualitative findings emphasized good user satisfaction. The identified themes suggested that the measurement system is acceptable, easy to use, and easy to access. Service users identified potential barriers and solutions to acceptability and ease of access. CONCLUSIONS A mixed methods evaluation of an electronic measurement system for automated, real-time monitoring of patients' experience of SDM showed that usability among patients was high. Future pilot work will optimize the system for wider implementation to ultimately inform intervention development to improve SDM. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2023-079155.
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Affiliation(s)
- Christin Hoffmann
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Kerry Avery
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Rhiannon Macefield
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Tadeáš Dvořák
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | | | - Jane Blazeby
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | | | - Shireen Hickey
- Improvement Academy, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Ben Gibbison
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Leila Rooshenas
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | | | | | - Hilary L Bekker
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
- The Research Centre for Patient Involvement (ResCenPI), Department of Public Health, Aarhus University, Central Denmark Region, Denmark
| | - Angus Gk McNair
- National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
- North Bristol NHS Trust, Bristol, United Kingdom
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Van den Wyngaert I, Van Pottelbergh G, Coteur K, Vaes B, Van den Bulck S. Developing a questionnaire to evaluate an automated audit & feedback intervention: a Rand-modified Delphi method. BMC Health Serv Res 2024; 24:433. [PMID: 38581009 PMCID: PMC10998400 DOI: 10.1186/s12913-024-10915-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 03/27/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Audit and feedback (A&F) is a widely used implementation strategy to evaluate and improve medical practice. The optimal design of an A&F system is uncertain and structured process evaluations are currently lacking. This study aimed to develop and validate a questionnaire to evaluate the use of automated A&F systems. METHODS Based on the Clinical Performance Feedback Intervention Theory (CP-FIT) and the REFLECT-52 (REassessing audit & Feedback interventions: a tooL for Evaluating Compliance with suggested besT practices) evaluation tool a questionnaire was designed for the purpose of evaluating automated A&F systems. A Rand-modified Delphi method was used to develop the process evaluation and obtain validation. Fourteen experts from different domains in primary care consented to participate and individually scored the questions on a 9-point Likert scale. Afterwards, the questions were discussed in a consensus meeting. After approval, the final questionnaire was compiled. RESULTS A 34-question questionnaire composed of 57 items was developed and presented to the expert panel. The consensus meeting resulted in a selection of 31 questions, subdivided into 43 items. A final list of 30 questions consisting of 42 items was obtained. CONCLUSION A questionnaire consisting of 30 questions was drawn up for the assessment and improvement of automated A&F systems, based on CP-FIT and REFLECT-52 theory and approved by experts. Next steps will be piloting and implementation of the questionnaire.
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Affiliation(s)
- Ine Van den Wyngaert
- Academic Centre for General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium.
| | - Gijs Van Pottelbergh
- Academic Centre for General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Kristien Coteur
- Academic Centre for General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Bert Vaes
- Academic Centre for General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Steve Van den Bulck
- Academic Centre for General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
- Research Group Healthcare and Ethics, Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
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Soresi J, Murray K, Marshall T, Preen DB. Longitudinal evaluation of an electronic audit and feedback system for patient safety in a large tertiary hospital setting. Health Informatics J 2024; 30:14604582241262707. [PMID: 38871668 DOI: 10.1177/14604582241262707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Objective: This study sought to assess the impact of a novel electronic audit and feedback (e-A&F) system on patient outcomes. Methods: The e-A&F intervention was implemented in a tertiary hospital and involved near real-time feedback via web-based dashboards. We used a segmented regression analysis of interrupted time series. We modelled the pre-post change in outcomes for the (1) announcement of this priority list, and (2) implementation of the e-A&F intervention to have affected patient outcomes. Results: Across the study period there were 222,792 episodes of inpatient care, of which 13,904 episodes were found to contain one or more HACs, a risk of 6.24%. From the point of the first intervention until the end of the study the overall risk of a HAC reduced from 8.57% to 4.12% - a 51.93% reduction. Of this reduction the proportion attributed to each of these interventions was found to be 29.99% for the announcement of the priority list and 21.93% for the implementation of the e-A&F intervention. Discussion: Our findings lend evidence to a mechanism that the announcement of a measurement framework, at a national level, can lead to local strategies, such as e-A&F, that lead to significant continued improvements over time.
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Affiliation(s)
- James Soresi
- North Metropolitan Health Service, Perth, WA, Australia
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | | | - David B Preen
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
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Liang H, Ye R, Song N, Zhu C, Xu M, Ye Q, Wei L, Chen J. Early ambulation protocol after diagnostic transfemoral cerebral angiography: an evidence-based practice project. BMC Neurol 2024; 24:104. [PMID: 38528480 DOI: 10.1186/s12883-024-03595-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/06/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND No uniform consensus has been achieved regarding the ambulation protocol after transfemoral cerebral angiography (TFA). Until now, in most hospitals patients are prescribed 8-12 h strict immobilization along with bed rest in the supine position after TFA in China, which causes great discomfort to patients. OBJECTIVE To evaluate the effect of an evidence-based early ambulation protocol on the prevention of vascular complications and general discomfort in patients following transfemoral cerebral angiography (TFA). METHODS A prospective quasi-experimental study was conducted on 214 patients undergoing TFA with manual compression. Patients in the experimental group were placed supine position for 2 h with a sandbag placed on the wound dressing, followed by a semi-seated position for another 2 h. After this period, patients took 2 h bed rest (move freely) with the sandbag removed, and were allowed to get out of bed 6 h after TFA. Patients in the control group were restricted to an 8 h bed rest in a supine position with the affected leg straight and immobilized. The vascular complications (bleeding, hematoma, ecchymosis) and levels of comfort (low back pain, leg pain, and blood pressure) were evaluated after the procedure. Numeric Rating Scale (NRS) pain scores, systolic blood pressure (SBP); diastolic blood pressure (DBP) were measured hourly for 8 h after TFA. RESULTS There was no significant difference in the two groups with regard to vascular complications including bleeding events (P = 0.621), bleeding volume (P = 0.321), and area of hematoma (P = 0.156). The area of ecchymosis in the experimental group was significantly smaller than the control group (P = 0.031). Compared with the control group, the NRS score for low back pain in the 4th, 5th, 6th, 7th, and 8th hour after TFA were significantly lower (P < 0.05), and the NRS score for leg pain in the 5th, 6th, 7th, 8th hour after TFA were significantly lower (P < 0.05). The SBP and DBP in the 6th, 7th, and 8th hour after TFA were significantly lower than the control group (all P < 0.05). CONCLUSIONS The evidence-based early ambulation protocol can effectively and safely increase comfort and decrease the pain level for patients undergoing TFA, without change in the incidence of vascular complications.
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Affiliation(s)
- Hao Liang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China
| | - Richun Ye
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China
| | - Nana Song
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China
| | - Canhui Zhu
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China
| | - Miaolong Xu
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China
| | - Qiaoyu Ye
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China
| | - Lin Wei
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China.
- State Key Laboratory of Traditional Chinese Medicine Syndrome/Department of Nursing, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 55 N, Neihuanxi Road, Guangzhou, 510006, Guangdong, China.
| | - Jiehan Chen
- Department of Neurology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine/Guangdong Provincial Hospital of Chinese medicine, Dade Road 111, Yuexiu District, Guangzhou510120, Guangdong, China.
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Anders A. Reconsidering performance management to support innovative changes in health care services. J Health Organ Manag 2024; 38:125-142. [PMID: 38546186 PMCID: PMC10988776 DOI: 10.1108/jhom-12-2022-0379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 12/15/2023] [Accepted: 02/18/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE A large number of studies indicate that coercive forms of organizational control and performance management in health care services often backfire and initiate dysfunctional consequences. The purpose of this article is to discuss new approaches to performance management in health care services when the purpose is to support innovative changes in the delivery of services. DESIGN/METHODOLOGY/APPROACH The article represents cross-boundary work as the theoretical and empirical material used to discuss and reconsider performance management comes from several relevant research disciplines, including systematic reviews of audit and feedback interventions in health care and extant theories of human motivation and organizational control. FINDINGS An enabling approach to performance management in health care services can potentially contribute to innovative changes. Key design elements to operationalize such an approach are a formative and learning-oriented use of performance measures, an appeal to self- and social-approval mechanisms when providing feedback and support for local goals and action plans that fit specific conditions and challenges. ORIGINALITY/VALUE The article suggests how to operationalize an enabling approach to performance management in health care services. The framework is consistent with new governance and managerial approaches emerging in public sector organizations more generally, supporting a higher degree of professional autonomy and the use of nonfinancial incentives.
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Affiliation(s)
- Anell Anders
- Department of Business Administration, Lund University
School of Economics and Management, Lund, Sweden
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Vullings N, Maas M, Adriaansen M, Vermeulen H, van der Wees P, Heinen M. Developing and testing a reflection method for implementation of the informal care guideline in community nursing: Design-based research. J Adv Nurs 2024. [PMID: 38515159 DOI: 10.1111/jan.16156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/20/2024] [Accepted: 03/02/2024] [Indexed: 03/23/2024]
Abstract
AIM To develop a reflection method for community nurses and certified nursing assistants to support the implementation of the Dutch Informal Care guideline in daily care. DESIGN Design-based research. METHODS A design group and four test groups of community nurses and nursing assistants were formed to develop a reflection method that aligns with the needs and preferences of its end-users. The design and test group meetings were video recorded. The video data were iteratively discussed and analysed thematically to adapt and refine the method and to identify its key features. RESULTS A final reflection method was developed. Five main themes were identified from the analysis: the group, reflective triggers, knowledge about the guidelines, the coach and preconditions. The themes are linked to nine key features representing the building blocks of the reflection method. The key features are group size, participants with different (educational) backgrounds, pairs of participants, expressing thoughts, video feedback, reflection game, making the connection with the guideline, coaching as a process facilitator and meeting organizational and contextual conditions for implementation. CONCLUSION An evidence- and practice-based reflection method for community nurses and certified nursing assistants is developed to support the implementation. By involving community nurses and certified nursing assistants, the method closely matches their needs and preferences. Critical elements of the reflection method are a game element, video feedback and working in pairs in a group of participants from different (educational) backgrounds. Guidance is needed to make the transfer from theory to practice. IMPACT A reflection method for community nurses and certified nursing assistants was developed to enhance care work according to guideline recommendations, aiming to improve the care provided by informal caregivers. REPORT METHOD The COREQ guideline was used. PATIENT OR PUBLIC CONTRIBUTION This reflection method was developed in close collaboration with all stakeholders during the entire study.
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Affiliation(s)
- Nicole Vullings
- Institute of Nursing Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Marjo Maas
- IQ Health Science Department, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marian Adriaansen
- Institute of Nursing Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- IQ Health Science Department, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip van der Wees
- IQ Health Science Department, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maud Heinen
- IQ Health Science Department, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
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Ahmad SZ, Ivers N, Zenlea I, Parsons JA, Shah BR, Mukerji G, Punthakee Z, Shulman R. An assessment of adaptation and fidelity in the implementation of an audit and feedback-based intervention to improve transition to adult type 1 diabetes care in Ontario, Canada. Implement Sci Commun 2024; 5:25. [PMID: 38500183 PMCID: PMC10946155 DOI: 10.1186/s43058-024-00563-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/03/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND The fit between an intervention and its local context may affect its implementation and effectiveness. Researchers have stated that both fidelity (the degree to which an intervention is delivered, enacted, and received as intended) and adaptation to the local context are necessary for high-quality implementation. This study describes the implementation of an audit and feedback (AF)-based intervention to improve transition to type 1 diabetes adult care, at five sites, in terms of adaptation and fidelity. METHODS An audit and feedback (AF)-based intervention for healthcare teams to improve transition to adult care for patients with type 1 diabetes was studied at five pediatric sites. The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) was used to document the adaptations made during the study. Fidelity was determined on three different levels: delivery, enactment, and receipt. RESULTS Fidelity of delivery, receipt, and enactment were preserved during the implementation of the intervention. Of the five sites, three changed their chosen quality improvement initiative, however, within the parameters of the study protocol; therefore, fidelity was preserved while still enabling participants to adapt accordingly. CONCLUSIONS We describe implementing a multi-center AF-based intervention across five sites in Ontario to improve the transition from pediatric to adult diabetes care for youth with type 1 diabetes. This intervention adopted a balanced approach considering both adaptation and fidelity to foster a community of practice to facilitate implementing quality improvement initiatives for improving transition to adult diabetes care. This approach may be adapted for improving transition care for youth with other chronic conditions and to other complex AF-based interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.
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Affiliation(s)
- Syed Zain Ahmad
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- SickKids Research Institute, Toronto, Canada
| | - Noah Ivers
- Women's College Institute for Health System Solutions and Virtual Care, Toronto, Canada
- Department of Family Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Ian Zenlea
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Janet A Parsons
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Baiju R Shah
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Canada
- ICES, Toronto, Canada
| | - Geetha Mukerji
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | - Zubin Punthakee
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Rayzel Shulman
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- SickKids Research Institute, Toronto, Canada.
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada.
- Department of Pediatrics, University of Toronto, Toronto, Canada.
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Michl G, Bail K, Turner M, Paterson C. Identifying the impact of audit and feedback on the professional role of the nurse and psychological well-being: An integrative systematic review. Nurs Health Sci 2024; 26:e13095. [PMID: 38438280 DOI: 10.1111/nhs.13095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 11/29/2023] [Accepted: 01/20/2024] [Indexed: 03/06/2024]
Abstract
This systematic review aimed to critically synthesis evidence to identify the impact that audit and feedback processes have on the professional role of the nurse and psychological well-being. Little is known about the extent to which audit and feedback processes can positively or negatively impact the professional role of the nurse and psychological well-being. An integrative systematic review was conducted. Covidence systematic review software was used to manage the screening process. Data extraction and methodological quality appraisal were conducted in parallel, and a narrative synthesis was conducted. Nurse participation and responsiveness to audit and feedback processes depended on self-perceived motivation, content, and delivery; and nurses viewed it as an opportunity for professional development. However, audit was reported to negatively impact nurses' psychological well-being, with impacts on burnout, stress, and demotivation in the workplace. Targeting framing, delivery, and content of audit and feedback is critical to nurses' satisfaction and successful quality improvement.
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Affiliation(s)
- Gabriella Michl
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Kasia Bail
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Murray Turner
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Catherine Paterson
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Robert Gordon University, Aberdeen, UK
- Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
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Klein L, Bentley M, Moad D, Fielding A, Tapley A, van Driel M, Davey A, Mundy B, FitzGerald K, Taylor J, Norris R, Holliday E, Magin P. Perceptions of the effectiveness of using patient encounter data as an education and reflection tool in general practice training. J Prim Health Care 2024; 16:12-20. [PMID: 38546767 DOI: 10.1071/hc22158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/18/2023] [Indexed: 04/02/2024] Open
Abstract
Introduction Patient encounter tools provide feedback and potentially reflection on general practitioner (GP) registrars' in-practice learning and may contribute to the formative assessment of clinical competencies. However, little is known about the perceived utility of such tools. Aim To investigate the perceived utility of a patient encounter tool by GP registrars, their supervisors, and medical educators (MEs). Methods General practice registrars, supervisors and MEs from two Australian regional training organisations completed a cross-sectional questionnaire. Registrars rated how Registrar Clinical Encounters in Training (ReCEnT), a patient encounter tool, influenced their reflection on, and change in, clinical practice, learning and training. Supervisors' and MEs' perceptions provided contextual information about understanding their registrars' clinical practice, learning and training needs. Results Questionnaires were completed by 48% of registrars (n = 90), 22% of supervisors (n = 182), and 61% of MEs (n = 62). Most registrars agreed that ReCEnT helped them reflect on their clinical practice (79%), learning needs (69%) and training needs (72%). Many registrars reported changing their clinical practice (54%) and learning approaches (51%). Fewer (37%) agreed that ReCEnT influenced them to change their training plans. Most supervisors (68%) and MEs (82%) agreed ReCEnT reports helped them better understand their registrars' clinical practice. Similarly, most supervisors (63%) and MEs (68%) agreed ReCEnT reports helped them better understand their registrars' learning and training needs. Discussion ReCEnT can prompt self-reflection among registrars, leading to changes in clinical practice, learning approaches and training plans. Reaching its potential as an assessment for learning (as opposed to an assessment of learning) requires effective engagement between registrars, their supervisors and MEs.
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Affiliation(s)
- Linda Klein
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Michael Bentley
- General Practice Training Tasmania, Level 3, RACT House, 179 Murray Street, Hobart, Tas. 7000, Australia
| | - Dominica Moad
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Alison Fielding
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Mieke van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, 288 Herston Road, Brisbane, Qld 4006, Australia
| | - Andrew Davey
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Ben Mundy
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Kristen FitzGerald
- General Practice Training Tasmania, Level 3, RACT House, 179 Murray Street, Hobart, Tas. 7000, Australia
| | - Jennifer Taylor
- GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Racheal Norris
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Parker Magin
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and GP Synergy, NSW and ACT Research and Evaluation Unit, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
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Melman A, Teng MJ, Coombs DM, Li Q, Billot L, Lung T, Rogan E, Marabani M, Hutchings O, Maher CG, Machado GC. A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study. JMIR Res Protoc 2024; 13:e50146. [PMID: 38386370 PMCID: PMC10921332 DOI: 10.2196/50146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia. OBJECTIVE The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model. METHODS This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes. RESULTS As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024). CONCLUSIONS This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/50146.
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Affiliation(s)
- Alla Melman
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
| | - Min Jiat Teng
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
- RPA Virtual Hospital, Sydney Local Health District, Sydney, Australia
| | - Danielle M Coombs
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Thomas Lung
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Eileen Rogan
- Department of Medicine, Canterbury Hospital, Sydney Local Health District, Sydney, Australia
| | - Mona Marabani
- Department of Medicine, Canterbury Hospital, Sydney Local Health District, Sydney, Australia
| | - Owen Hutchings
- RPA Virtual Hospital, Sydney Local Health District, Sydney, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
| | - Gustavo C Machado
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
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Stewart C, Power E, McCluskey A, Kuys S, Lovarini M. Implementing ward-based practice books to increase the amount of practice completed during inpatient stroke rehabilitation: a mixed-methods process evaluation. Disabil Rehabil 2024:1-11. [PMID: 38386409 DOI: 10.1080/09638288.2024.2315502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
PURPOSE Stroke survivors must complete large amounts of practice to achieve functional improvements but spend many hours inactive during their rehabilitation. We conducted a mixed methods process evaluation exploring factors affecting the success of a 6-month behaviour change intervention to increase use of ward-based practice books. METHODS Audits of the presence, quality and use of ward based-practice books were conducted, alongside focus groups with staff (n = 19), and interviews with stroke survivors (n = 3) and family members (n = 4). Quantitative data were analysed descriptively. Focus group and interview transcripts were analysed using qualitative analysis. RESULTS Personal (patient-related) factors (including severe weakness, cognitive and communication deficits of stroke survivors), staff coaching skills, understanding and beliefs about their role, affected practice book use. Staff turnover, nursing shift work and a lack of action planning reduced success of the behaviour change intervention. CONCLUSIONS Staff with the necessary skills and understanding of their role in implementing ward practice overcame personal (patient-related) factors and assisted stroke survivors to successfully practice on the ward. To improve success of the intervention, repeated training of new staff is required. In addition to audit and feedback, team action planning is needed around the presence, quality, and use of ward practice books.
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Affiliation(s)
- Claire Stewart
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | - Emma Power
- The University of Technology Sydney, Graduate School of Health, Sydney, Australia
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Annie McCluskey
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
- The StrokeEd Collaboration, Sydney, Australia
| | - Suzanne Kuys
- School of Allied Health, Australian Catholic University, Banyo, Australia
| | - Meryl Lovarini
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
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Shojania KG. Is targeting healthcare's carbon footprint really the best we can do to help address the climate crisis? BMJ Qual Saf 2024; 33:205-208. [PMID: 37666662 DOI: 10.1136/bmjqs-2023-016312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Kaveh G Shojania
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Cassidy CE, Flynn R, Campbell A, Dobson L, Langley J, McNeil D, Milne E, Zanoni P, Churchill M, Benzies KM. Knowledge translation strategies used for sustainability of an evidence-based intervention in child health: a multimethod qualitative study. BMC Nurs 2024; 23:125. [PMID: 38368328 PMCID: PMC10874067 DOI: 10.1186/s12912-024-01777-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/30/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Sustainability of evidence-based interventions (EBIs) is suboptimal in healthcare. Evidence on how knowledge translation (KT) strategies are used for the sustainability of EBIs in practice is lacking. This study examined what and how KT strategies were used to facilitate the sustainability of Alberta Family Integrated Care (FICare)™, a psychoeducational model of care scaled and spread across 14 neonatal intensive care units, in Alberta, Canada. METHODS First, we conducted an environmental scan of relevant documents to determine the use of KT strategies to support the sustainability of Alberta FICare™. Second, we conducted semi-structured interviews with decision makers and operational leaders to explore what and how KT strategies were used for the sustainability of Alberta FICare™, as well as barriers and facilitators to using the KT strategies for sustainability. We used the Expert Recommendations for Implementation Change (ERIC) taxonomy to code the strategies. Lastly, we facilitated consultation meetings with the Alberta FICare™ leads to share and gain insights and clarification on our findings. RESULTS We identified nine KT strategies to facilitate the sustainability of Alberta FICare™: Conduct ongoing training; Identify and prepare local champions; Research co-production; Remind clinicians; Audit and provide feedback; Change record systems; Promote adaptability; Access new funding; and Involve patients/consumers and family members. A significant barrier to the sustainability of Alberta FICare™ was a lack of clarity on who was responsible for the ongoing maintenance of the intervention. A key facilitator to sustainability of Alberta FICare was its alignment with the Maternal, Newborn, Child & Youth Strategic Clinical Network (MNCY SCN) priorities. Co-production between researchers and health system partners in the design, implementation, and scale and spread of Alberta FICare™ was critical to sustainability. CONCLUSION This research highlights the importance of clearly articulating who is responsible for continued championing for the sustainability of EBIs. Additionally, our research demonstrates that the adaptation of interventions must be considered from the onset of implementation so interventions can be tailored to align with contextual barriers for sustainability. Clear guidance is needed to continually support researchers and health system leaders in co-producing strategies that facilitate the long-term sustainability of effective EBIs in practice.
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Affiliation(s)
- Christine E Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, 5869 University Avenue, B3H 4R2, Halifax, NS, PO Box 15000, Canada.
| | - Rachel Flynn
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College of Cork, College Road, T12 AK54, Cork, Ireland
| | - Alyson Campbell
- Faculty of Nursing, University of Prince Edward Island, 550 University Avenue, HSB Room 116, C1A 4P3, Charlottetown, PE, Canada
| | - Lauren Dobson
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Level 3, 11405 87 Avenue, T6G 1C9, Edmonton, AB, Canada
| | - Jodi Langley
- Faculty of Health, Dalhousie University, 5790 University Avenue, B3H 1V7, Halifax, NS, Canada
| | - Deborah McNeil
- Strategic Clinical Networks, Alberta Health Services, 10101 Southport Road SW, T2W 3N2, Calgary, AB, Canada
- Faculty of Nursing, Departments of Pediatrics and Community Health Science, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, T2N 1N4, Calgary, AB, Canada
| | - Ella Milne
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Level 3, 11405 87 Avenue, T6G 1C9, Edmonton, AB, Canada
| | - Pilar Zanoni
- Faculty of Nursing , University of Calgary, 2500 University Drive NW, T2N 1N4, Calgary, AB, Canada
| | - Megan Churchill
- Department of Pediatrics, IWK Health, 5980 University Ave #5850, B3K 6R8, Halifax, NS, Canada
| | - Karen M Benzies
- Faculty of Nursing, Departments of Pediatrics and Community Health Science, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, T2N 1N4, Calgary, AB, Canada
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Desveaux L, Ivers N. Practice or perfect? Coaching for a growth mindset to improve the quality of healthcare. BMJ Qual Saf 2024:bmjqs-2023-016456. [PMID: 38355297 DOI: 10.1136/bmjqs-2023-016456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/28/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Laura Desveaux
- Trillium Health Partners Institute for Better Health, Mississauga, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Alghamdi S, Dixon N, Al-Senani F, Al Aseri Z, Al Saif S, AlTahan T. Effects of a team Quality Improvement method in a national clinical audit programme of four clinical specialties in Ministry of Health hospitals in Saudi Arabia. Int J Qual Health Care 2024; 36:mzad107. [PMID: 38153764 PMCID: PMC10842466 DOI: 10.1093/intqhc/mzad107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/29/2023] [Accepted: 12/24/2023] [Indexed: 12/29/2023] Open
Abstract
In 2018, the Ministry of Health (MoH) in Saudi Arabia developed a clinical excellence strategy. An objective was to reduce variation in clinical practices in MoH hospitals, particularly for conditions with high mortality in Saudi Arabia, by applying best practice clinical standards and using the clinical audit process to measure clinical practice. The strategy included working with multiprofessional teams in hospitals to implement improvements needed in clinical practice. To test the feasibility of carrying out national clinical audits in MoH hospitals, audits were carried out in 16 MoH hospitals on four clinical subjects-acute myocardial infarction, major trauma, sepsis, and stroke. Clinical expert groups, including Saudi clinicians and an international clinical expert, developed clinical care standards for the four conditions from analyses of international and Saudi clinical guidelines. The audits were designed with the expert groups. Multiprofessional teams were appointed to carry out the audits in designated MoH hospitals. Data collectors in each hospital were trained to collect data. Workshops were held with the teams on the clinical care standards and how data would be collected for the audits, and later, on the findings of data collection and how to use the improvement process to implement changes to improve compliance with the standards. After 4 months, data collection was repeated to determine if compliance with the clinical care standards had improved. Data collected from each hospital for both cycles of data collection were independently reliably tested. All designated hospitals participated in the audits, collecting and submitting data for two rounds of data collection and implementing improvement plans after the first round of data collection. All hospitals made substantial improvements in clinical practices. Of a total of 84 measures used to assess compliance with a total of 52 clinical care standards for the four clinical conditions, improvements were made by hospital teams in 58 (69.1%) measures. Improvements were statistically significant for 34 (40.5%) measures. The project demonstrated that well-designed and executed audits using evidence-based clinical care standards can result in substantial improvements in clinical practices in MoH hospitals in Saudi Arabia. Keys to success were the improvement methodology built into the audit process and the requirement for hospitals to appoint multiprofessional teams to carry out the audits. The approach adds to evidence on the effectiveness of clinical audits in achieving improvements in clinical quality and can be replicated in national audit programmes.
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Affiliation(s)
- Saleh Alghamdi
- Clinical Excellence General Directorate, Ministry of Health, Riyadh 14726, Saudi Arabia
| | - Nancy Dixon
- Healthcare Quality Quest, Shelley Farm, Shelley Lane, Ower, Romsey, Hampshire SO51 6AS, United Kingdom
| | - Fahmi Al-Senani
- Stroke Saudi Clinical Expert Group, Model of Care Programme, Ministry of Health, Riyadh 11525, Saudi Arabia
| | - Zohair Al Aseri
- Sepsis Saudi Clinical Expert Group, Departments of Emergency and Critical Care, College of Medicine, King Saud University and Department of Clinical Sciences, College of Medicine, Riyadh Hospital, Dar Al Uloom University, Adult ICU services, Ministry of Health, Riyadh 145111, Saudi Arabia
| | - Shukri Al Saif
- Myocardial Infarction Saudi Clinical Expert Group, Eastern Health Cluster, Saudi Al-Babtain Cardiac Centre, Qatif, Dammam 32632, Saudi Arabia
| | - Talal AlTahan
- Major Trauma Saudi Clinical Expert Group, Prince Mohammed Bin Abdulaziz Hospital, Riyadh 14214, Saudi Arabia
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Dinis A, Fernandes Q, Wagenaar BH, Gimbel S, Weiner BJ, John-Stewart G, Birru E, Gloyd S, Etzioni R, Uetela D, Ramiro I, Gremu A, Augusto O, Tembe S, Mário JL, Chinai JE, Covele AF, Sáide CM, Manaca N, Sherr K. Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework. BMC Health Serv Res 2024; 24:164. [PMID: 38308300 PMCID: PMC10835896 DOI: 10.1186/s12913-024-10638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.
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Affiliation(s)
- Aneth Dinis
- National Department of Public Health, Ministry of Health, Maputo City, Mozambique.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Quinhas Fernandes
- National Department of Public Health, Ministry of Health, Maputo City, Mozambique
| | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Child, Family & Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ermyas Birru
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Stephen Gloyd
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ruth Etzioni
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | | | | | - Artur Gremu
- Comité para Saúde de Moçambique, Maputo, Mozambique
| | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, WA, USA
- Eduardo Mondlane University, Maputo, Mozambique
| | - Stélio Tembe
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Nélia Manaca
- Comité para Saúde de Moçambique, Maputo, Mozambique
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA, USA
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Tavares W, Sockalingam S, Valanci S, Giuliani M, Davis D, Campbell C, Silver I, Charow R, Jeyakumar T, Younus S, Wiljer D. Performance Data Advocacy for Continuing Professional Development in Health Professions. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:153-158. [PMID: 37824840 DOI: 10.1097/acm.0000000000005490] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
ABSTRACT Efforts to optimize continuing professional development (CPD) are ongoing and include advocacy for the use of clinician performance data. Several educational and quality-based frameworks support the use of performance data to achieve intended improvement outcomes. Although intuitively appealing, the role of performance data for CPD has been uncertain and its utility mainly assumed. In this Scholarly Perspective, the authors briefly review and trace arguments that have led to the conclusion that performance data are essential for CPD. In addition, they summarize and synthesize a recent and ongoing research program exploring the relationship physicians have with performance data. They draw on Collins, Onwuegbuzie, and Johnson's legitimacy model and Dixon-Woods' integrative approach to generate inferences and ways of moving forward. This interpretive approach encourages questioning or raising of assumptions about related concepts and draws on the perspectives (i.e., interpretive work) of the research team to identify the most salient points to guide future work. The authors identify 6 stimuli for future programs of research intended to support broader and better integration of performance data for CPD. Their aims are to contribute to the discourse on data advocacy for CPD by linking conceptual, methodologic, and analytic processes and to stimulate discussion on how to proceed on the issue of performance data for CPD purposes. They hope to move the field from a discussion on the utility of data for CPD to deeper integration of relevant conceptual frameworks.
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Madder RD, Seth M, Frazier K, Dixon S, Karve M, Collins J, Miller RV, Pielsticker E, Sharma M, Sukul D, Gurm HS. Statewide Initiative to Reduce Patient Radiation Doses During Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2024; 17:e013502. [PMID: 38348649 DOI: 10.1161/circinterventions.123.013502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/06/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND Improved radiation safety practices are needed across hospitals performing percutaneous coronary intervention (PCI). This study was performed to assess the temporal trend in PCI radiation doses concurrent with the conduct of a statewide radiation safety initiative. METHODS A statewide initiative to reduce PCI radiation doses was conducted in Michigan between 2017 and 2021 and included focused radiation safety education, reporting of institutional radiation doses, and implementation of radiation performance metrics for hospitals. Using data from a large statewide registry, PCI discharges between July 1, 2016, and July 1, 2022, having a procedural air kerma (AK) recorded were analyzed for temporal trends. A multivariable regression analysis was performed to determine whether declines in procedural AK over time were attributable to changes in known predictors of radiation doses. RESULTS Among 131 619 PCI procedures performed during the study period, a reduction in procedural AK was observed over time, from a median dose of 1.46 (0.86-2.37) Gy in the first year of the study to 0.97 (0.56-1.64) Gy in the last year of the study (P<0.001). The proportion of cases with an AK ≥5 Gy declined from 4.24% to 0.86% over the same time period (P<0.0001). After adjusting for variables known to impact radiation doses, a 1-year increase in the date of PCI was associated with a 7.61% (95% CI, 7.38%-7.84%) reduction in procedural AK (P<0.0001). CONCLUSIONS Concurrent with the conduct of a statewide initiative to reduce procedural radiation doses, a progressive and significant decline in procedural radiation doses was observed among patients undergoing PCI in the state of Michigan.
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Affiliation(s)
- Ryan D Madder
- Frederik Meijer Heart and Vascular Institute, Division of Cardiovascular Medicine, Corewell Health West, Grand Rapids, MI (R.D.M.)
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (M.S., K.F., D.S., H.S.G.)
| | - Kathleen Frazier
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (M.S., K.F., D.S., H.S.G.)
| | - Simon Dixon
- Department of Cardiovascular Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (S.D.)
| | | | - John Collins
- Ascension St. Mary's Hospital, Saginaw, MI (J.C.)
| | | | | | | | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (M.S., K.F., D.S., H.S.G.)
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (M.S., K.F., D.S., H.S.G.)
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