Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

Rationale and design of the comparison of outcomes and access to care for heart failure (COACH) trial: A stepped wedge cluster randomized trial

BACKGROUND

Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF.

OBJECTIVES

We will evaluate an intervention comprised of 2 complementary components: (1) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and (2) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death.

STUDY DESIGN

Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: (1) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or (2) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation.

CONCLUSION

This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.

Potentially inappropriate medications and medication combinations before, during and after hospitalizations: an analysis of pathways and determinants in the Swiss healthcare setting

Background

A hospitalization phase represents a challenge to medication safety especially for multimorbid patients as acute medical needs might interact with pre-existing medications or evoke adverse drug effects. This project aimed to examine the prevalence and risk factors of potentially inappropriate medications (PIMs) and medication combinations (PIMCs) in the context of hospitalizations.

Methods

Analyses are based on claims data of patients (≥65 years) with basic mandatory health insurance at the Helsana Group, and on data from the Hirslanden Swiss Hospital Group. We assessed PIMs and PIMCs of patients who were hospitalized in 2013 at three different time points (quarter prior, during, after hospitalization). PIMs were identified using the PRISCUS list, whereas PIMCs were derived from compendium.ch. Zero-inflated Poisson regression models were applied to determine risk factors of PIMs and PIMCs.

Results

Throughout the observation period, more than 80% of patients had at least one PIM, ranging from 49.7% in the pre-hospitalization, 53.6% in the hospitalization to 48.2% in the post-hospitalization period. PIMCs were found in 46.6% of patients prior to hospitalization, in 21.3% during hospitalization, and in 25.0% of patients after discharge. Additional medication prescriptions compared to the preceding period and increasing age were the main risk factors, whereas managed care was associated with a decrease in PIMs and PIMCs.

Conclusion

We conclude that a patient’s hospitalization offers the possibility to increase medication safety. Nevertheless, the prevalence of PIMs and PIMCs is relatively high in the study population. Therefore, our results indicate a need for interventions to increase medication safety in the Swiss healthcare setting.

Even High-Quality CPGs Seldom Include Implementation Strategies

Background: Implementation is a key step in ensuring that high-quality clinical practice guideline (CPG) recommendations are followed and have a positive impact. This step must be planned during CPG development. This study aims to inform professionals tasked with developing and implementing CPGs regarding implementation strategies and tools reported in high-quality CPGs for chronic non-communicable diseases (NCDs).

Methods: NCD guidelines were selected based on Appraisal of Guideline Research and Evaluation (AGREE) II assessment. CPGs with a score of ≥60% in AGREE II domains 3 (rigor of development), 5 (applicability), and 6 (editorial independence), were considered high quality. The content related to implementation was extracted from CPG full texts and complementary materials. Implementation strategies and tools were assessed and classified using Mazza taxonomy.

Results: Twenty high-quality CPGs were selected, most of which were developed by government institutions (16; 80%) with public funding (16; 80%); almost half (9; 45%) addressed the treatment of cardiovascular diseases. The countries with the most high-quality CPGs were the UK (6; 30%) and Colombia (5; 25%). These countries also had the highest average number of strategies, Colombia with 28 (SD = 1) distributed in all levels, and the UK with 15 (SD = 7), concentrating on professional and organizational levels. Although the content of the Colombian CPGs was similar regardless the disease, the CPGs from the UK were specific and contained data-based feedback reports and information on CPG compliance. Implementation strategies most frequently identified were at the professional level, such as distributing reference material (18; 80%) and educating groups of healthcare professionals (18; 80%). At the organizational level, the most frequent strategies involve changes in structure (15; 75%) and service delivery method (13; 65%).

Conclusion: Countries with established CPG programs, such as the UK and Colombia, where identified as having the highest number of high-quality CPGs, although CPG implementation content had significant differences. Among high-quality CPGs, the most common implementation strategies were at the professional and organizational levels. There is still room for improvement regarding the implementation strategies report, even among high-quality CPGs, especially concerning monitoring of implementation outcomes and selection of strategies based on relevant implementation barriers.

Effectiveness of Digital Technologies to Support Nursing Care: Results of a Scoping Review

Background

The field of digital technologies being developed or applied to support nursing care is extensive. The aim of this scoping review is to provide an overview on technologies for which results on positive or negative effects on persons in need of care, caregivers or care institutions are available and to appraise the reliability of these results.

Methods

A scoping review design has been used to identify studies focussing on the effectiveness of digital technologies in nursing care for persons in need of care, caregivers or care institutions. The screening process included 19,510 scientific publications from 9 databases.

Results

A total of 123 single studies and 31 reviews were subjected to the analysis. The included technologies comprise nursing and health information technologies, such as assistive devices, information and communication technologies, sensors and robotics. The results show that there are many studies that demonstrate positive effects, but the level of evidence is mostly low and study sizes are often small. Hardly any technology has been researched intensively enough to produce conclusive results. Studies on a high level of evidence (RCTs) lack for most technological areas. Heterogeneous results in some areas indicate that effects may depend strongly on the mode and specific context into which the technologies are introduced.

Conclusion

Due to the limited evidence on effectiveness of digital technologies in nursing care, it is not surprising that care institutions are reluctant to put innovative technologies into practice. The scoping review indicates technology areas that should be subject to future research with higher quality studies. Research on outpatient, informal and cross-sectoral care should be intensified to further exploit the potential of digital technologies with a view to improving independence of care-recipients and unburdening formal and informal carers.

Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

OBJECTIVES

New clinical practice guidelines for the management of mild traumatic brain injury (mTBI) emphasise that family physicians should proactively screen and initiate treatment for depression/anxiety, insomnia and headaches. This study aimed to evaluate the feasibility of delivering an implementation intervention to family physicians.

DESIGN

Pilot cluster randomised controlled trial.

SETTING

Specialty outpatient clinic (recruitment) and primary care (implementation).

PARTICIPANTS

114 primary care clinics were randomised. These clinics were associated with 137 unique family physicians caring for 148 adult patients who sustained an mTBI within the previous 3 months and were seeking care for persistent symptoms.

INTERVENTIONS

Patients completed self-report screening measures for depression/anxiety, insomnia and headaches. A tailored letter that incorporates the patient's screening test results and associated treatment algorithms was sent to their family physician (or walk-in clinic). Physicians at clinics assigned to the control condition received a generic letter, without the screening test results.

PRIMARY OUTCOME MEASURES

Feasibility outcomes included the frequency of primary care follow-up, retention rates and reliability of patient recall of their physicians' actions (primary mechanistic outcome). The primary efficacy outcome was the Rivermead Post-Concussion Symptom Questionnaire (RPQ).

RESULTS

Most patients (97.8%; 128 of 131) followed up at the primary care clinic they planned to. Retention rates were 88% (131 of 148) and 78% (116 of 148) at the 1-month and 3-month assessments, respectively. Agreement between patient recall of their physicians' actions and medical chart audits was moderate (intraclass correlation coefficient=0.48-0.65). Patients in the experimental group reported fewer symptoms on the RPQ compared with those in the control group, whose physician received a general letter (B=-4.0, 95% CI: -7.3 to -0.7).

CONCLUSIONS

A larger trial will need to address minor feasibility challenges to evaluate the effectiveness of this guideline implementation tool for improving mTBI clinical outcomes and confirm the mechanism(s) of intervention benefit.

TRIAL REGISTRATION NUMBER

NCT03221218.

The effectiveness of interventions to increase preventive care provision for chronic disease risk behaviours in mental health settings: A systematic review and meta-analysis

Clinical practice guidelines direct mental health services to provide preventive care to address client chronic disease risk behaviours, however, this care is not routinely provided. The aim of this systematic review was to synthesise evidence regarding the effectiveness of interventions to increase provision of preventive care by mental health services; by care element (ask, assess, advice, assist, arrange) and risk behaviour (tobacco smoking, poor nutrition, harmful alcohol consumption, physical inactivity). Electronic bibliographic databases, Google Scholar, relevant journals, and included study reference lists were searched. Eligible studies were of any design with a comparison group that reported the effectiveness of an intervention to increase the provision of at least one element of preventive care for at least one risk behaviour in a mental health setting. Twenty studies were included, most commonly examining smoking (n = 20) and 'ask' (n = 12). Meta-analysis found interventions involving task shifting were effective in increasing smoking 'advice' (n = 2 RCTs; p = 0.009) and physical activity 'advice' (n = 2 RCTs; p = 0.002). Overall, meta-analysis and narrative synthesis indicated that effective intervention strategies (categorised according to the Effective Practice and Organisation of Care taxonomy) were: task shifting, educational meetings, health information systems, local consensus processes, authority and accountability, and reminders. The most consistent findings across studies were with regard to preventive care for smoking, while conflicting or limited evidence was found regarding other risk behaviours. While further rigorous research examining key risk behaviours is recommended, the findings may inform the selection of strategies for future interventions and service delivery initiatives.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement evidence-based policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to: 1. Examine the cost or cost-effectiveness of such strategies; 2. Examine any adverse effects of such strategies on childcare services, service staff or children; 3. Examine the effect of such strategies on child diet, physical activity or weight status. 4. Describe the acceptability, adoption, penetration, sustainability and appropriateness of such implementation strategies.

SEARCH METHODS

We searched the following electronic databases on February 22 2019: Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, Embase, PsycINFO, ERIC, CINAHL and SCOPUS for relevant studies. We searched reference lists of included studies, handsearched two international implementation science journals, the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or nonrandomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy. Centre-based childcare services included preschools, nurseries, long daycare services and kindergartens catering for children prior to compulsory schooling (typically up to the age of five to six years).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened study titles and abstracts, extracted study data and assessed risk of bias; we resolved discrepancies via consensus. We performed meta-analysis using a random-effects model where studies with suitable data and homogeneity were identified; otherwise, findings were described narratively.

MAIN RESULTS

Twenty-one studies, including 16 randomised and five nonrandomised, were included in the review. The studies sought to improve the implementation of policies, practices or programmes targeting healthy eating (six studies), physical activity (three studies) or both healthy eating and physical activity (12 studies). Studies were conducted in the United States (n = 12), Australia (n = 8) and Ireland (n = 1). Collectively, the 21 studies included a total of 1945 childcare services examining a range of implementation strategies including educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing, reminders and tailored interventions. Most studies (n = 19) examined implementation strategies versus usual practice or minimal support control, and two compared alternative implementation strategies. For implementation outcomes, six studies (one RCT) were judged to be at high risk of bias overall. The review findings suggest that implementation strategies probably improve the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention in childcare services. Of the 19 studies that compared a strategy to usual practice or minimal support control, 11 studies (nine RCTs) used score-based measures of implementation (e.g. childcare service nutrition environment score). Nine of these studies were included in pooled analysis, which found an improvement in implementation outcomes (SMD 0.49; 95% CI 0.19 to 0.79; participants = 495; moderate-certainty evidence). Ten studies (seven RCTs) used dichotomous measures of implementation (e.g. proportion of childcare services implementing a policy or specific practice), with seven of these included in pooled analysis (OR 1.83; 95% CI 0.81 to 4.11; participants = 391; low-certainty evidence). Findings suggest that such interventions probably lead to little or no difference in child physical activity (four RCTs; moderate-certainty evidence) or weight status (three RCTs; moderate-certainty evidence), and may lead to little or no difference in child diet (two RCTs; low-certainty evidence). None of the studies reported the cost or cost-effectiveness of the intervention. Three studies assessed the adverse effects of the intervention on childcare service staff, children and parents, with all studies suggesting they have little to no difference in adverse effects (e.g. child injury) between groups (three RCTs; low-certainty evidence). Inconsistent quality of the evidence was identified across review outcomes and study designs, ranging from very low to moderate. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used.

AUTHORS' CONCLUSIONS

Current research suggests that implementation strategies probably improve the implementation of policies, practices or programmes by childcare services, and may have little or no effect on measures of adverse effects. However such strategies appear to have little to no impact on measures of child diet, physical activity or weight status.

Doubling Hepatitis C Virus Screening in Primary Care Using Advanced Electronic Health Record Tools-A Non-Randomized Controlled Trial

BACKGROUND

Hepatitis C virus (HCV) infection is a major public health burden, affecting over 4 million people. The Centers for Disease Control and Prevention and the US Preventive Services Task Force guidelines recommend screening everyone born between 1945 and 1965, but screening rates remain low.

OBJECTIVE

To determine whether bulk ordering and electronic messaging to patients improves guideline-based HCV screening rates.

DESIGN

A non-randomized controlled trial of 1024 adults from November 2016 to March 2017.

PARTICIPANTS

Patients due for HCV screening with at least one primary care office visit in one of three primary care clinics and enrolled in the healthcare system's tethered personal health record (tPHR).

INTERVENTIONS

Control patients received normal care for HCV screening, consisting of passive HCV reminders to providers during face-to-face visits and passive HCV screening notification through the patient's tPHR. Intervention patients received normal care and also had HCV antibody tests ordered for them and customized messages sent through their tPHR inviting them to go directly to the lab for HCV screening over a 12-week period.

MAIN MEASURES

Percentage/number of patients receiving HCV antibody tests during the intervention period. Percentage/number of intervention group patients receiving HCV screening with other blood work.

KEY RESULTS

In the intervention group, 33% (168 of 514) completed HCV testing, compared with 19% (97 of 510) of controls (OR 1.7, 95% CI 1.2-2.1). Bulk lab ordering appeared to have a large impact while bulk messaging appeared to have a less significant role.

CONCLUSIONS

Leveraging population analytics and bulk ordering in an electronic health record with bulk messaging to a tPHR directly engages patients in blood screening tests and can significantly improve completion. This methodology has a broad range of applications including many recommended screening or disease-specific testing. This bulk ordering and direct-to-patient messaging approach improves patient screening while decreasing provider/staff work.

TRIAL REGISTRATION

MetroHealth IRB16-00776 (ClinicalTrials.gov).

Evidence-based care in high- and low-risk groups following whiplash injury: a multi-centre inception cohort study

BACKGROUND

Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mitigating the effect of EBC is the relationship with the practitioner, a phenomenon poorly understood in WAD. This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether receiving EBC and the therapeutic relationship were associated with recovery at 3 months post injury.

METHODS

Participants with acute whiplash were recruited from public hospital emergency departments, private physiotherapy practices, and State Insurance Regulatory Authority (SIRA) databases. Participants completed questionnaires at baseline (demographics, risk of non-recovery) and 3-months (treatment received, risk identification, therapeutic relationship) post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as neck disability index ≤4/50 and global perceived effect of ≥4/5.

RESULTS

Two-hundred and twenty-eight people with acute whiplash, and 53 primary care practitioners were recruited. The majority of the cohort reported receiving EBC, with correct application of the Canadian C-spine rule (74%), and provision of active treatments (e.g. 89% receiving advice) high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. 50% receiving massage). The therapeutic relationship was associated with higher odds of recovery, which was potentially clinically significant (OR 1.34, 95% CI 1.18-1.62). EBC was not significantly associated with recovery.

CONCLUSIONS

Guideline-based knowledge and practice has largely been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. The therapeutic relationship was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.

Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review

INTRODUCTION

Nudge-interventions aimed at health professionals are proposed to reduce the overuse and underuse of health services. However, little is known about their effectiveness at changing health professionals' behaviours in relation to overuse or underuse of tests or treatments.

OBJECTIVE

The aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services.

METHODS AND ANALYSIS

We will perform a systematic review. All study designs that include a control comparison will be included. Any qualified health professional, across any specialty or setting, will be included. Only nudge-interventions aimed at altering the behaviour of health professionals will be included. We will examine the effect of choice architecture nudges (default options, active choice, framing effects, order effects) and social nudges (accountable justification and pre-commitment or publicly declared pledge/contract). Studies with outcomes relevant to overuse or underuse of health services will be included. Relevant studies will be identified by a computer-aided search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, CINAHL, Embase and PsycINFO databases. Two independent reviewers will screen studies for eligibility, extract data and perform the risk of bias assessment using the criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We will report our results in a structured synthesis format, as recommended by the Cochrane EPOC group.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature.

Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines

Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.

Digital technology and nursing care: a scoping review on acceptance, effectiveness and efficiency studies of informal and formal care technologies

BACKGROUND

The existence, usage and benefits of digital technologies in nursing care are relevant topics in the light of the current discussion on technologies as possible solutions to problems such as the shortage of skilled workers and the increasing demand for long-term care. A lack of good empirical overviews of existing technologies in the present literature prompted us to conduct this review. Its purpose was to map the field of digital technologies for informal and formal care that have already been explored in terms of acceptance, effectiveness and efficiency (AEE), and to show the scope of the used methods, target settings, target groups and fields of support.

METHODS

A systematic literature search was conducted using Medline, Scopus, CINAHL, Cochrane Library, ACM Digital Library, IEEE Xplore, the Collection of Computer Science Bibliographies, GeroLit and CareLit. In addition, project websites were manually screened for relevant publications.

RESULTS

Seven hundred fifteen papers were included in the review. Effectiveness studies have been most frequently performed for ICT, robots and sensors. Acceptance studies often focussed on ICT, robots and EHR/EMR. Efficiency studies were generally rare. Many studies were found to have a low level of evidence. Experimental designs with small numbers and without control groups were the most common methods used to evaluate acceptance and effectiveness. Study designs with high evidence levels were most commonly found for ICT, robots and e-learning. Technologies evaluated for informal caregivers and children or indicated for formal care at home or in cross-sectoral care were rare.

CONCLUSION

We recommend producing high-quality evaluations on existing digital technologies for AEE in real-life settings rather than systematic reviews with low-quality studies. More focus should be placed on research into efficiency. Future research should be devoted to a closer examination of the applied AEE evaluation methods. Policymakers should provide funding to enable large-scale, long-term evaluations of technologies in the practice of care, filling the research gaps for technologies, target settings and target groups identified in this review.

Testing e-mail content to encourage physicians to access an audit and feedback tool: a factorial randomized experiment

Background

In Ontario, an online audit and feedback tool that provides primary care physicians with detailed information about patients who are overdue for cancer screening is underused. In the present study, we aimed to examine the effect of messages operationalizing 3 behaviour change techniques on access to the audit and feedback tool and on cancer screening rates.

Methods

During May-September 2017, a pragmatic 2×2×2 factorial experiment tested 3 behaviour change techniques: anticipated regret, material incentive, and problem-solving. Outcomes were assessed using routinely collected administrative data. A qualitative process evaluation explored how and why the e-mail messages did or did not support Screening Activity Report access.

Results

Of 5449 primary care physicians randomly allocated to 1 of 8 e-mail messages, fewer than half opened the messages and fewer than 1 in 10 clicked through the messages. Messages with problem-solving content were associated with a 12.9% relative reduction in access to the tool (risk ratio: 0.871; 95% confidence interval: 0.791 to 0.958; p = 0.005), but a 0.3% increase in cervical cancer screening (rate ratio: 1.003; 95% confidence interval: 1.001 to 1.006; p = 0.003). If true, that association would represent 7568 more patients being screened. No other significant effects were observed.

Conclusions

For audit and feedback to work, recipients must engage with the data; for e-mail messages to prompt activity, recipients must open and review the message content. This large factorial experiment demonstrated that small changes in the content of such e-mail messages might influence clinical behaviour. Future research should focus on strategies to make cancer screening more user-centred.

Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework

Purpose: Inadvertent perioperative hypothermia is a significant problem for surgical patients globally, and is associated with many detrimental side-effects. Despite the availability of rigorously developed international evidence-based guidelines for prevention, a high incidence of this complication persists. This qualitative study aims to identify and examine the domains which act as barriers and enablers to perioperative hypothermia prevention practices, from the perspectives of the key healthcare professionals involved with perioperative temperature management. Methods: A qualitative study employing semi-structured interviews was utilized. A purposive sample of key stakeholders involved in perioperative temperature management, including perioperative nurses, anesthetists, surgeons, and perioperative managers, were recruited via email. The interview guide was developed in reference to the Theoretical Domains Framework. All interviews were recorded, de-identified, transcribed, and coded. Belief statements were generated within each domain, and a frequency score generated for each belief. Finally, the domains were mapped to the COM-B model of the Behavior Change Wheel to develop recommendations for future interventions. Results: Twelve participants were included including eight nurses, two surgeons, and two anesthetists. Eleven key theoretical domains that influence the uptake of perioperative hypothermia practices were identified: knowledge; skills; social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; goals; memory, attention, and decision processes; environmental context and resources; social influence. Suggested intervention strategies include training, reminder systems, audit, and feedback, organizational support to resolve lack of control of ambient temperature, as well as provision of accurate temperature measurement devices. Conclusion: Future interventions to address the key behavioral domains and improve perioperative hypothermia prevention need to be evaluated in the context of feasibility, effectiveness, safety, acceptability, and cost by the target users. All suggested intervention strategies need to take a team-based, multi-modal approach, as this is most likely to facilitate improvements in perioperative hypothermia prevention.

Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility

Background

Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk.

Objective

The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele–hipertensão arterial sistêmica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country.

Methods

The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews.

Results

Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients’ treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment.

Conclusions

In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices.

Beginning with high value care in mind: A scoping review and toolkit to support the content, delivery, measurement, and sustainment of high value care

OBJECTIVE

To create a shared vision for the content, delivery, measurement, and sustainment of patient-centered high value care.

METHODS

We performed a scoping review and translated findings into toolkit for system leaders. For our scoping review, we searched Medline, 2005-November 2015, for literature on patient-centered care (PCC) and its relationship to a high value care change model. We supplemented searches with key author, Google Scholar, and key website searches. One author reviewed all titles, abstracts, and articles for inclusion; another reviewed a random 20%. To develop our toolkit, we translated evidence into simple, actionable briefs on key topics and added resources. We then iteratively circulated briefs and the overall toolkit to potential users, making updates as needed.

RESULTS

In our scoping review, we found multiple interventions and measures to support the components of PCC and our change model. We found little on the overall effects of PCC or how PCC creates value. Potential users reported our toolkit was simple, understandable, thorough, timely, and likely to be globally useful.

CONCLUSIONS

Considerable evidence supports patient-centered high value care and a toolkit garnered enthusiasm.

PRACTICE IMPLICATIONS

The toolkit is ready for use, but needs comparison to other approaches.

Exploring the role of competing demands and routines during the implementation of a self-management tool for type 2 diabetes: a theory-based qualitative interview study

BACKGROUND

The implementation of new medical interventions into routine care involves healthcare professionals adopting new clinical behaviours and changing existing ones. Whilst theory-based approaches can help understand healthcare professionals' behaviours, such approaches often focus on a single behaviour and conceptualise its performance in terms of an underlying reflective process. Such approaches fail to consider the impact of non-reflective influences (e.g. habit and automaticity) and how the myriad of competing demands for their time may influence uptake. The current study aimed to apply a dual process theoretical approach to account for reflective and automatic determinants of healthcare professional behaviour while integrating a multiple behaviour approach to understanding the implementation and use of a new self-management tool by healthcare professionals in the context of diabetes care.

METHODS

Following Diabetes UK's national release of the 'Information Prescription' (DUK IP; a self-management tool targeting the management of cholesterol, blood pressure and HbA1c) in January 2015, we conducted semi-structured interviews with 13 healthcare professionals (general practitioners and nurses) who had started to use the DUK IP during consultations to provide self-management advice to people with type 2 diabetes. A theory-based topic guide included pre-specified constructs from a previously developed logic model. We elicited healthcare professionals' views on reflective processes (outcome expectations, self-efficacy, intention, action and coping planning), automatic processes (habit), and multiple behaviour processes (goal priority, goal conflict and goal facilitation). All interviews were audio recorded and transcribed verbatim and all transcripts were independently double coded and analysed using content analysis.

RESULTS

The majority of healthcare professionals interviewed reported strong intentions to use the DUK IP and having formed a habit of using them after a minimum of one month continuous use. Pop-up cues in the electronic patient records were perceived to facilitate the use of the tool. Factors that conflicted with the use of the DUK IP included existing pathways of providing self-management advice.

CONCLUSION

Data suggests that constructs from dual process and multiple behaviour approaches are useful to provide supplemental understanding of the implementation of new self-management tools such as the DUK IP and may help to advance behavioural approaches to implementation science.

What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review

Background

Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation.

Methods

A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation.

Results

Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions.

Conclusions

Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.

Effect of Peer Comparison Letters for High-Volume Primary Care Prescribers of Quetiapine in Older and Disabled Adults: A Randomized Clinical Trial

IMPORTANCE

Antipsychotic agents, such as quetiapine fumarate, are frequently overprescribed for indications not supported by clinical evidence, potentially causing harm.

OBJECTIVE

To investigate if peer comparison letters targeting high-volume primary care prescribers of quetiapine meaningfully reduce their prescribing.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial (intent to treat) conducted from 2015 to 2017 of prescribers and their patients nationwide in the Medicare program. The trial targeted the 5055 highest-volume primary care prescribers of quetiapine in 2013 and 2014 (approximately 5% of all primary care prescribers of quetiapine).

INTERVENTIONS

Prescribers were randomized (1:1 ratio) to receive a placebo letter or 3 peer comparison letters stating that their quetiapine prescribing was high relative to their peers and was under review by Medicare.

MAIN OUTCOMES AND MEASURES

The primary outcome was the total quetiapine days supplied by prescribers from the intervention start to 9 months. Secondary outcomes included quetiapine receipt from all prescribers by baseline patients, quetiapine receipt by patients with low-value or guideline-concordant indications for therapy, mortality, and hospital use. In exploratory analyses, the study followed outcomes to 2 years.

RESULTS

Of the 5055 prescribers, 231 (4.6%) were general practitioners, 2428 (48.0%) were in family medicine, and 2396 (47.4%) were in internal medicine; 4155 (82.2%) were male. All were included in the analyses. Over 9 months, the treatment arm supplied 11.1% fewer quetiapine days per prescriber vs the control arm (2456 vs 2864 days; percentage difference, 11.1% fewer days; 95% CI, -13.1% to -9.2% days; P < .001; adjusted difference, -319 days; 95% CI, -374 to -263 days; P < .001), which persisted through 2 years (15.6% fewer days; 95% CI, -18.1% to -13.0%; P < .001). At the patient level, individuals in the treatment arm received 3.9% (95% CI, -5.0% to -2.9%; P < .001) fewer days of quetiapine from all prescribers over 9 months, with a larger decrease among patients with low-value vs guideline-concordant indications (-5.9% [95% CI, -8.0% to -3.9%] vs -2.4% [95% CI, -4.0% to -0.9%], P = .01 for test that effects were equal for both patient groups). There was no evidence of substitution to other antipsychotics, and 9-month mortality and hospital use were similar between the treatment vs control arms.

CONCLUSIONS AND RELEVANCE

Peer comparison letters caused substantial and durable reductions in quetiapine prescribing, with no evidence of negative effects on patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02467933.

A systematic review of trials evaluating success factors of interventions with computerised clinical decision support

BACKGROUND

Computerised clinical decision support (CDS) can potentially better inform decisions, and it can help with the management of information overload. It is perceived to be a key component of a learning health care system. Despite its increasing implementation worldwide, it remains uncertain why the effect of CDS varies and which factors make CDS more effective.

OBJECTIVE

To examine which factors make CDS strategies more effective on a number of outcomes, including adherence to recommended practice, patient outcome measures, economic measures, provider or patient satisfaction, and medical decision quality.

METHODS

We identified randomised controlled trials, non-randomised trials, and controlled before-and-after studies that directly compared CDS implementation with a given factor to CDS without that factor by searching CENTRAL, MEDLINE, EMBASE, and CINAHL and checking reference lists of relevant studies. We considered CDS with any objective for any condition in any healthcare setting. We included CDS interventions that were either displayed on screen or provided on paper and that were directed at healthcare professionals or targeted at both professionals and patients. The reviewers screened the potentially relevant studies in duplicate. They extracted data and assessed risk of bias in independent pairs or individually followed by a double check by another reviewer. We summarised results using medians and interquartile ranges and rated our certainty in the evidence using the GRADE system.

RESULTS

We identified 66 head-to-head trials that we synthesised across 14 comparisons of CDS intervention factors. Providing CDS automatically versus on demand led to large improvements in adherence. Displaying CDS on-screen versus on paper led to moderate improvements and making CDS more versus less patient-specific improved adherence modestly. When CDS interventions were combined with professional-oriented strategies, combined with patient-oriented strategies, or combined with staff-oriented strategies, then adherence improved slightly. Providing CDS to patients slightly increased adherence versus CDS aimed at the healthcare provider only. Making CDS advice more explicit and requiring users to respond to the advice made little or no difference. The CDS intervention factors made little or no difference to patient outcomes. The results for economic outcomes and satisfaction outcomes were sparse.

CONCLUSION

Multiple factors may affect the success of CDS interventions. CDS may be more effective when the advice is provided automatically and displayed on-screen and when the suggestions are more patient-specific. CDS interventions combined with other strategies probably also improves adherence. Providing CDS directly to patients may also positively affect adherence. The certainty of the evidence was low to moderate for all factors.

TRIAL REGISTRATION

PROSPERO, CRD42016033738.

Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care

BACKGROUND

As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs).

METHODS

The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results.

RESULTS

The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]).

DISCUSSION

Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.

The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

Background

Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed.

Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully.

Methods

We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist.

Results

We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy.

Conclusions

The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0772-3) contains supplementary material, which is available to authorized users.

Development of a Tailored Intervention With Computerized Clinical Decision Support to Improve Quality of Care for Patients With Knee Osteoarthritis: Multi-Method Study

BACKGROUND

Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery.

OBJECTIVE

This study aimed to tailor a guideline-based computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis.

METHODS

Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors.

RESULTS

The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient.

CONCLUSIONS

The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time.

Systematic review of interventions to increase the provision of care for chronic disease risk behaviours in mental health settings: review protocol

BACKGROUND

People with a mental illness experience a higher morbidity and mortality from chronic diseases relative to the general population. A higher prevalence of risk behaviours, including tobacco smoking, poor nutrition, harmful alcohol consumption and physical inactivity, is a substantial contributor to this health inequity. Clinical practice guidelines recommend that mental health services routinely provide care to their clients to address these risk behaviours. Such care may include the following elements: ask, assess, advise, assist and arrange (the '5As'), which has been demonstrated to be effective in reducing risk behaviours. Despite this potential, the provision of such care is reported to be low internationally and in Australia, and there is a need to identify effective strategies to increase care provision. The proposed review will examine the effectiveness of interventions which aimed to increase care provision (i.e. increase the proportion of clients receiving or clinicians providing the 5As) for the chronic disease risk behaviours of clients within the context of mental health service delivery.

METHODS

Eligible studies will be any quantitative study designs with a comparison group and which report on the effectiveness of an intervention strategy (including delivery arrangements, financial arrangements, governance arrangements and implementation strategies) to increase care provision specifically for chronic disease risk behaviours (tobacco smoking, poor nutrition, harmful alcohol consumption and physical inactivity). Screening for studies will be conducted across seven electronic databases: PsycINFO, MEDLINE, Excerpta Medica database (EMBASE), Psychology and Behavioural Sciences Collection, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two authors will independently screen studies for eligibility and extract data from included studies. Where studies are sufficiently homogenous, meta-analysis will be performed. Where considerable heterogeneity exists (I 2  ≥ 75), narrative synthesis will be used.

DISCUSSION

This review will be the first to synthesise evidence for the effectiveness of intervention approaches to facilitate care provision for chronic disease risk behaviours in the context of mental health service delivery. The results have the potential to inform the development of evidenced-based approaches to address the health inequities experienced by this population group.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074360 .

A Cluster Randomised Controlled Trial of a Brief Child Health Nurse Intervention to Reduce Infant Secondhand Smoke Exposure

Background Exposure to secondhand smoke (SHS) is a significant contributor to ill health in children. A study was undertaken to determine the effectiveness of two brief multi-strategic child health nurse delivered interventions in: decreasing the prevalence of infants exposed to SHS; decreasing the prevalence of smoking amongst parent/carers of infants and increasing the prevalence of household smoking bans. Methods This study was a 3 arm, cluster randomised controlled trial. Clusters were 39 community based well child health clinics in one local area health service. Clinics were stratified according to annual number of client appointments and then randomly assigned in a 1:1:1 ratio, (Intervention 1: Intervention 2: Control), with 13 clinics in each cluster. Parents/carers of infants in the intervention groups received a brief multi-strategic intervention from child health nurses during clinic consultations. Treatment condition 1 included computer delivered risk assessment and feedback and nurse brief advice. Treatment condition 2 included all elements of Treatment condition 1 with the addition of biochemical feedback of infant SHS exposure. Results When compared to the Control group at 12 months, no significant differences in the prevalence of infant exposure to SHS were detected from baseline to follow-up for Treatment condition 1 (OR 1.16, 95 % CI 0.73-1.85, p = 0.53) or Treatment condition 2 (OR 1.30, 95 % CI 0.88-1.92, p = 0.19) Similarly, no significant differences were detected in the proportion of parent/carers who reported that they were smokers (T1:OR 0.95, 95 % CI 0.78-1.15, p = 0.58 and T2:OR 0.97, 95 % CI 0.80-1.18, p = 0.77), or in the proportion of households reported to have a complete smoking ban (T1:OR 1.21, 95 % CI 0.89-1.64, p = 0.23 and T2:OR 1.06, 95 % CI 0.79-1.43, p = 0.68). Conclusions Further research is required to identify effective interventions that can be consistently provided by child health nurses if the potential of such settings to contribute to reductions in child SHS exposure is to be realised.

Identifying Which Urban Children With Asthma Benefit Most From Clinician Prompting: Subgroup Analyses From the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) Trial

OBJECTIVE

Clinician prompts increase the likelihood of guideline-recommended corrective actions (preventive medication prescription, dose change, and/or adherence promotion) for symptomatic children with poorly controlled or persistent asthma in the primary care setting, but it is unclear if all children equally benefit. The objectives of this study were to identify whether asthma severity, visit type, and current preventive medication use were predictive of corrective actions during visits for children with symptomatic asthma, and determine whether these factors modified the effect of a prompting intervention.

METHODS

We conducted prespecified subgroup analyses of a cluster randomized controlled trial of physician prompting that promoted guideline-based asthma management for urban children with symptomatic asthma. We tested predictors of corrective actions with bivariate and multivariate multilevel logistic regressions, compared intervention effects across factor categories via stratified analyses, and characterized effect modification with interaction term analyses.

RESULTS

Prompting intervention exposure, moderate/severe disease, asthma-focused visits, and current preventive medication use were predictive of corrective actions. The prompting intervention significantly increased the rate of corrective actions for children across categories of disease severity, visit type, and preventive medication use. However, the intervention effect was significantly smaller for children already using a preventive medication (adjusted odds ratio [OR], 2.01; 95% confidence interval [CI], 1.19-3.38) compared with children without preventive medication use (adjusted OR, 6.25; 95% CI, 3.39-11.54).

CONCLUSIONS

Prompting increases the likelihood of corrective actions during clinic encounters; however, children already using preventive medication benefit less. It is critical for providers to recognize the need for corrective actions among these symptomatic children.

Testing Behavior Change Techniques to Encourage Primary Care Physicians to Access Cancer Screening Audit and Feedback Reports: Protocol for a Factorial Randomized Experiment of Email Content

Background

Cancer Care Ontario’s Screening Activity Report (SAR) is an online audit and feedback tool designed to help primary care physicians in Ontario, Canada, identify patients who are overdue for cancer screening or have abnormal results requiring follow-up. Use of the SAR is associated with increased screening rates. To encourage SAR use, Cancer Care Ontario sends monthly emails to registered primary care physicians announcing that updated data are available. However, analytics reveal that 50% of email recipients do not open the email and less than 7% click the embedded link to log in to their report.

Objective

The goal of the study is to determine whether rewritten emails result in increased log-ins. This manuscript describes how different user- and theory-informed messages intended to improve the impact of the monthly emails will be experimentally tested and how a process evaluation will explore why and how any effects observed were (or were not) achieved.

Methods

A user-centered approach was used to rewrite the content of the monthly email, including messages operationalizing 3 behavior change techniques: anticipated regret, material incentive (behavior), and problem solving. A pragmatic, 2x2x2 factorial experiment within a multiphase optimization strategy will test the redesigned emails with an embedded qualitative process evaluation to understand how and why the emails may or may not have worked. Trial outcomes will be ascertained using routinely collected administrative data. Physicians will be recruited for semistructured interviews using convenience and snowball sampling.

Results

As of April 2017, 5576 primary care physicians across the province of Ontario, Canada, had voluntarily registered for the SAR, and in so doing, signed up to receive the monthly email updates. From May to August 2017 participants received the redesigned monthly emails with content specific to their allocated experimental condition prompting use of the SAR. We have not yet begun analyses.

Conclusions

This study will inform how to communicate effectively with primary care providers by email and identify which behavior change techniques tested are most effective at encouraging engagement with an audit and feedback report.

Trial Registration

ClinicalTrials.gov NCT03124316; https://clinicaltrials.gov/ct2/show/NCT03124316 (Archived by WebCite at http://www.webcitation.org/6w2MqDWGu)

Enhancing prescribing of guideline-recommended medications for ischaemic heart diseases: a systematic review and meta-analysis of interventions targeted at healthcare professionals

OBJECTIVES

Ischaemic heart diseases (IHDs) are a leading cause of death worldwide. Although prescribing according to guidelines improves health outcomes, it remains suboptimal. We determined whether interventions targeted at healthcare professionals are effective to enhance prescribing and health outcomes in patients with IHDs.

METHODS

We systematically searched PubMed and EMBASE for studies published between 1 January 2000 and 31 August 2017. We included original studies of interventions targeted at healthcare professionals to enhance prescribing guideline-recommended medications for IHDs. We only included randomised controlled trials (RCTs). Main outcomes were the proportion of eligible patients receiving guideline-recommended medications, the proportion of patients achieving target blood pressure and target low-density lipoprotein-cholesterol (LDL-C)/cholesterol level and mortality rate. Meta-analyses were performed using the inverse-variance method and the random effects model. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

We included 13 studies, 4 RCTs (1869 patients) and 9 cluster RCTs (15 224 patients). 11 out of 13 studies were performed in North America and Europe. Interventions were of organisational or professional nature. The interventions significantly enhanced prescribing of statins/lipid-lowering agents (OR 1.23; 95% CI 1.07 to 1.42, P=0.004), but not other medications (aspirin/antiplatelet agents, beta-blockers, ACE inhibitors/angiotensin II receptor blockers and the composite of medications). There was no significant association between the interventions and improved health outcomes (target LDL-C and mortality) except for target blood pressure (OR 1.46; 95% CI 1.11 to 1.93; P=0.008). The evidence was of moderate or high quality for all outcomes.

CONCLUSIONS

Organisational and professional interventions improved prescribing of statins/lipid-lowering agents and target blood pressure in patients with IHDs but there was little evidence of change in other outcomes.

PROSPERO REGISTRATION NUMBER

CRD42016039188.

The Basic Science of Behavior Change and Its Application to Pediatric Providers

Pediatric primary care providers (PPCPs) are increasingly expected to know how to assess, diagnose, and treat a wide range of mental health problems in children and adolescents. For many PPCPs, this means learning and performing new practice behaviors that were not taught in their residency training. Typical continuing education approaches to engage PPCPs in new practices have not yielded the desired changes in provider behavior. This article summarizes behavior change principles identified through basic behavior science, adult education, and communication research, and discusses their application to a patient-centered pediatric primary care mental health curriculum.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.

AUTHORS' CONCLUSIONS

Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Cardiovascular care guideline implementation in community health centers in Oregon: a mixed-methods analysis of real-world barriers and challenges

BACKGROUND

Spreading effective, guideline-based cardioprotective care quality improvement strategies between healthcare settings could yield great benefits, particularly in under-resourced contexts. Understanding the diverse factors facilitating or impeding such guideline implementation could improve cardiovascular care quality and outcomes for vulnerable patients.

METHODS

We sought to identify multi-level factors affecting uptake of cardioprotective care guidelines in community health centers (CHCs), within a successful trial of cross-setting implementation of an effective intervention. Quantitative analyses used multivariable logistic regression to examine in-person patient encounters at 10 CHCs from June 2011-May 2014. At these encounters, a point-of-care alert flagged adults with diabetes who were clinically indicated for, but not currently prescribed, cardioprotective medications. The main outcome measure was the rate of relevant prescriptions issued within two days of encounters. Qualitative analyses focused on CHC providers and staff, and, guided by the constant comparative method, were used to enhance understanding of the factors that influenced this prescribing.

RESULTS

Recommended prescribing occurred at 13-16% of encounters with patients who were indicated for such prescribing. The odds of this prescribing were higher when the patient was male, had HbA1c ≥7, was previously prescribed a similar medication, gave diabetes as the chief complaint, saw a mid-level practitioner, or saw their primary care provider. The odds were lower when the patient was insured, had ≥1 clinic visits in the past year, had kidney disease, or was prescribed certain other medications. Additional factors were associated with prescribing of each medication class. Qualitative results both supported and challenged the quantitative findings, illustrating important tensions involved in guideline-based prescribing. Clinic staff stressed the importance of the provider-patient relationship in guiding prescribing decisions in the face of competing priorities and care needs, and the impact of rapidly changing guidelines.

CONCLUSIONS

Diverse factors associated with guideline-concordant prescribing illuminate the complexity of delivering evidence-based care in CHCs. We present possible strategies for addressing barriers to guideline-based prescribing.

CLINICAL TRIALS REGISTRATION

This trial was registered retrospectively. Currently Controlled Trials NCT02299791 . Retrospectively registered 10 November 2014.

Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers

Inappropriate prescribing is a rising threat to the health of Medicare beneficiaries and a drain on Medicare's finances. In this study we used a randomized controlled trial approach to evaluate a low-cost, light-touch intervention aimed at reducing the inappropriate provision of Schedule II controlled substances in the Medicare Part D program. Potential overprescribers were sent a letter explaining that their practice patterns were highly unlike those of their peers. Using rich administrative data, we were unable to detect an effect of these letters on prescribing. We describe ongoing efforts to build on this null result with alternative interventions. Learning about the potential of light-touch interventions, both effective and ineffective, will help produce a better toolkit for policy makers to improve the value and safety of health care.

Access to fracture risk assessment by FRAX and linked National Osteoporosis Guideline Group (NOGG) guidance in the UK-an analysis of anonymous website activity

In the UK, fracture risk guidance is provided by the National Osteoporosis Guideline Group (NOGG). NOGG usage showed widespread access through direct web-based linkage to FRAX. The facilitated interaction between fracture risk assessment and clinical guidelines could usefully be adopted in other countries.

INTRODUCTION

In the UK, guidance on assessment of osteoporosis and fracture risk is provided by the National Osteoporosis Guideline Group ( www.shef.ac.uk/NOGG ). We wished to determine access to this guidance by exploring website activity.

METHODS

We undertook an analysis of FRAX and NOGG website usage for the year between 1^st July 2013 and 30^th June 2014 using Google Analytics software.

RESULTS

During this period, there was a total of 1,774,812 sessions (a user interaction with the website) on the FRAX website with 348,964 of these from UK-based users; 253,530 sessions were recorded on the NOGG website. Of the latter, two-thirds were returning visitors, with the vast majority (208,766; 82 %) arising from sites within the UK. The remainder of sessions were from other countries demonstrating that some users of FRAX in other countries make use of the NOGG guidance. Of the UK-sourced sessions, the majority was from England, but the session rate (adjusted for population) was the highest for Scotland. Almost all (95.7 %) of the UK sessions arose from calculations being passed through from the FRAX tool ( www.shef.ac.uk/FRAX ) to the NOGG website, comprising FRAX calculations in patients without a bone mineral density (BMD) measurement (74.5 %) or FRAX calculations with a BMD result (21.2 %). National Health Service (NHS) sites were identified as the major source of visits to the NOGG website, comprising 79.9 % of the identifiable visiting locations, but this is an underestimate as many sites from within the NHS are not classified as such.

CONCLUSION

The study shows that the facilitated interaction between web-based fracture risk assessment and clinical guidelines is widely used in the UK. The approach could usefully be adopted in other countries for which a FRAX model is available.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to:1. describe the impact of such strategies on childcare service staff knowledge, skills or attitudes;2. describe the cost or cost-effectiveness of such strategies;3. describe any adverse effects of such strategies on childcare services, service staff or children;4. examine the effect of such strategies on child diet, physical activity or weight status.

SEARCH METHODS

We searched the following electronic databases on 3 August 2015: the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, ERIC, CINAHL and SCOPUS. We also searched reference lists of included trials, handsearched two international implementation science journals and searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or non-randomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy.

DATA COLLECTION AND ANALYSIS

The review authors independently screened abstracts and titles, extracted trial data and assessed risk of bias in pairs; we resolved discrepancies via consensus. Heterogeneity across studies precluded pooling of data and undertaking quantitative assessment via meta-analysis. However, we narratively synthesised the trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We identified 10 trials as eligible and included them in the review. The trials sought to improve the implementation of policies and practices targeting healthy eating (two trials), physical activity (two trials) or both healthy eating and physical activity (six trials). Collectively the implementation strategies tested in the 10 trials included educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing. A total of 1053 childcare services participated across all trials. Of the 10 trials, eight examined implementation strategies versus a usual practice control and two compared alternative implementation strategies. There was considerable study heterogeneity. We judged all studies as having high risk of bias for at least one domain.It is uncertain whether the strategies tested improved the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention. No intervention improved the implementation of all policies and practices targeted by the implementation strategies relative to a comparison group. Of the eight trials that compared an implementation strategy to usual practice or a no intervention control, however, seven reported improvements in the implementation of at least one of the targeted policies or practices relative to control. For these trials the effect on the primary implementation outcome was as follows: among the three trials that reported score-based measures of implementation the scores ranged from 1 to 5.1; across four trials reporting the proportion of staff or services implementing a specific policy or practice this ranged from 0% to 9.5%; and in three trials reporting the time (per day or week) staff or services spent implementing a policy or practice this ranged from 4.3 minutes to 7.7 minutes. The review findings also indicate that is it uncertain whether such interventions improve childcare service staff knowledge or attitudes (two trials), child physical activity (two trials), child weight status (two trials) or child diet (one trial). None of the included trials reported on the cost or cost-effectiveness of the intervention. One trial assessed the adverse effects of a physical activity intervention and found no difference in rates of child injury between groups. For all review outcomes, we rated the quality of the evidence as very low. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used in this review.

AUTHORS' CONCLUSIONS

Current research provides weak and inconsistent evidence of the effectiveness of such strategies in improving the implementation of policies and practices, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. Further research in the field is required.

Evaluation of a training program for medicines-oriented policymakers to use a database of systematic reviews

BACKGROUND

Suboptimal prescribing and medications use is a problem for health systems globally. Systematic reviews are a comprehensive resource that can help guide evidence-informed decision-making and implementation of interventions addressing such issues; however, a barrier to the use of systematic reviews is their inaccessibility (due to both dispersion across journals and inaccessibility of content). Publicly available databases, such as Rx for Change, provide quick access to summaries of appraised systematic reviews of professional and consumer-oriented interventions to improve prescribing behaviour and appropriate medication use, and may help maximise the use of evidence to inform decisions. The present study aims to evaluate a training program to improve attitudes towards, confidence in skills, intentions to use, and use of systematic review evidence contained within Rx for Change.

METHODS

Guided by the Knowledge to Action framework, a training program with content customised to local provider and consumer contexts was developed with knowledge user input. The training program consisted of a 6 minute information video, a 1 hour workshop with hands-on, interactive and didactic components, and two post-training reminders. Forty-nine people from five medicines-focused organisations in Canada and Australia attended one of six workshops. Participants were surveyed immediately pre and post and 3 months after training to evaluate their attitudes towards, confidence in skills, intentions to use, and use of Rx for Change, and attitudes towards and confidence in skills for using evidence for decision-making. Analyses for differences for each of the outcomes at three time points (pre, post and 3 months after training) was performed using a random effects model.

RESULTS

Immediately post-training, there were higher respondent attitudes towards Rx for Change (mean increase = 0.54 out of 5, 95% CI, 0.18-0.83, P < 0.005); intention to use Rx for Change (0.53, 95% CI, 0.21-0.86, P < 0.005); confidence in skills for using Rx for Change (2.08, 95% CI, 1.74-2.42, P < 0.005); and confidence in skills for using evidence in policy decision-making (0.50, 95% CI, 0.22-0.77, P < .005) compared to pre-training. Confidence in skills for using both Rx for Change and evidence were maintained 3 months after training (both P < 0.005).

CONCLUSIONS

Participants of this training program reported sustained improvements in their confidence in skills for using evidence in policy decision-making. This may have important implications for uptake of systematic review evidence promoting improved prescribing and medication use.

Implementation interventions to improve the management of non-specific low back pain: a systematic review

BACKGROUND

Recommendations in clinical practice guidelines for non-specific low back pain (NSLBP) are not necessarily translated into practice. Multiple studies have investigated different interventions to implement best evidence into clinical practice yet no synthesis of these studies has been carried out to date. The aim of this study was to systematically review available studies to determine whether implementation interventions in this field have been effective and to identify which strategies have been most successful in changing healthcare practitioner behaviours and improving patient outcomes.

METHODS

A systematic review was undertaken, searching electronic databases until end of December 2012 plus hand searching, writing to key authors and using prior knowledge of the field to identify papers. Included studies evaluated an implementation intervention to improve the management of NSLBP in clinical practice, measured key outcomes regarding change in practitioner behaviour and/or patient outcomes and subjected their data to statistical analysis. The Cochrane Effective Practice and Organisation of Care (EPOC) recommendations about systematic review conduct were followed. Study inclusion, data extraction and study risk of bias assessments were conducted independently by two review authors.

RESULTS

Of 7654 potentially eligible citations, 17 papers reporting on 14 studies were included. Risk of bias of included studies was highly variable with 7 of 17 papers rated at high risk. Single intervention or one-off implementation efforts were consistently ineffective in changing clinical practice. Increasing the frequency and duration of implementation interventions led to greater success with those continuously ongoing over time the most successful in improving clinical practice in line with best evidence recommendations.

CONCLUSIONS

Single intervention or one-off implementation interventions may seem attractive but are largely unsuccessful in effecting meaningful change in clinical practice for NSLBP. Increasing frequency and duration of implementation interventions seems to lead to greater success and the most successful implementation interventions used consistently sustained strategies.

Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings

Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice.

METHODS

A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables.

RESULTS

Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention.

CONCLUSIONS

This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.

Effectiveness of an intervention in increasing the provision of preventive care by community mental health services: a non-randomized, multiple baseline implementation trial

BACKGROUND

Relative to the general population, people with a mental illness are more likely to have modifiable chronic disease health risk behaviours. Care to reduce such risks is not routinely provided by community mental health clinicians. This study aimed to determine the effectiveness of an intervention in increasing the provision of preventive care by such clinicians addressing four chronic disease risk behaviours.

METHODS

A multiple baseline trial was undertaken in two groups of community mental health services in New South Wales, Australia (2011-2014). A 12-month practice change intervention was sequentially implemented in each group. Outcome data were collected continuously via telephone interviews with a random sample of clients over a 3-year period, from 6 months pre-intervention in the first group, to 6 months post intervention in the second group. Outcomes were client-reported receipt of assessment, advice and referral for tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption and inadequate physical activity and for the four behaviours combined. Logistic regression analyses examined change in client-reported receipt of care.

RESULTS

There was an increase in assessment for all risks combined following the intervention (18 to 29 %; OR 3.55, p = 0.002: n = 805 at baseline, 982 at follow-up). No significant change in assessment, advice or referral for each individual risk was found.

CONCLUSIONS

The intervention had a limited effect on increasing the provision of preventive care. Further research is required to determine how to increase the provision of preventive care in community mental health services.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12613000693729.

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention

BACKGROUND

Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice.

METHODS

We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention).

RESULTS

Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn't engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity.

CONCLUSIONS

A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices.

Health Systems Approaches to Diabetes Screening and Prevention in Women with a History of Gestational Diabetes

Gestational diabetes (GDM) is associated with a high risk of future type 2 diabetes. Despite multiple clinical guidelines highlighting the importance of screening in this high-risk population, many health systems report that fewer than 50 % of eligible women are screened in the postpartum period, and little is known about screening beyond the first postpartum year. Systems-level approaches to screening for and prevention of type 2 diabetes in women with a history of GDM are therefore an opportunity for quality improvement. This review will discuss the literature on interventions to improve screening at the systems level and highlight successful strategies as well as gaps in the existing literature. Future directions for intervention research are suggested.

Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial

BACKGROUND

People with dementia are susceptible to adverse drug reactions (ADRs). However, they are not always closely monitored for potential problems relating to their medicines: structured nurse-led ADR Profiles have the potential to address this care gap. We aimed to assess the number and nature of clinical problems identified and addressed and changes in prescribing following introduction of nurse-led medicines' monitoring.

DESIGN

Pragmatic cohort stepped-wedge cluster Randomised Controlled Trial (RCT) of structured nurse-led medicines' monitoring versus usual care.

SETTING

Five UK private sector care homes.

PARTICIPANTS

41 service users, taking at least one antipsychotic, antidepressant or anti-epileptic medicine.

INTERVENTION

Nurses completed the West Wales ADR (WWADR) Profile for Mental Health Medicines with each participant according to trial step.

OUTCOMES

Problems addressed and changes in medicines prescribed.

DATA COLLECTION AND ANALYSIS

Information was collected from participants' notes before randomisation and after each of five monthly trial steps. The impact of the Profile on problems found, actions taken and reduction in mental health medicines was explored in multivariate analyses, accounting for data collection step and site.

RESULTS

Five of 10 sites and 43 of 49 service users approached participated. Profile administration increased the number of problems addressed from a mean of 6.02 [SD 2.92] to 9.86 [4.48], effect size 3.84, 95% CI 2.57-4.11, P <0.001. For example, pain was more likely to be treated (adjusted Odds Ratio [aOR] 3.84, 1.78-8.30), and more patients attended dentists and opticians (aOR 52.76 [11.80-235.90] and 5.12 [1.45-18.03] respectively). Profile use was associated with reduction in mental health medicines (aOR 4.45, 1.15-17.22).

CONCLUSION

The WWADR Profile for Mental Health Medicines can improve the quality and safety of care, and warrants further investigation as a strategy to mitigate the known adverse effects of prescribed medicines.

TRIAL REGISTRATION

ISRCTN 48133332.

Using EMR to improve compliance with clinical practice guidelines for management of stable COPD

BACKGROUND

Clinical practice guidelines are underutilized in the outpatient management of chronic obstructive pulmonary disease (COPD). We hypothesize that a structured approach using the electronic medical record (EMR) will improve compliance with clinical practice guidelines for the evaluation and management of patients with stable COPD.

METHODS

Clinical records were evaluated in a pre- and post-intervention analysis of patients with COPD seen in our pulmonary clinics at a single tertiary care academic setting. Patient charts were retrospectively screened for the diagnosis of COPD and individually assessed for a diagnosis of COPD by spirometry. We then developed and implemented a COPD Flowsheet based on clinical practice guidelines into each outpatient clinic encounter for COPD with repeat chart review of clinic patients. Improvement in the pre- to post-intervention quality metrics were compared using t-test and Chi squared as indicated. A p-value of <0.05 was considered significant.

RESULTS

A total of 200 patients were screened in the pre-intervention period and 347 in the post-intervention period. Of these, 144 (72%) and 267 (77%) met criteria for COPD based on FEV(1)/FVC < 0.70, respectively. There was a significant increase in the use of severity assessment by BODE index (13.2% vs 32.2%, p-value < 0.001), inhaler technique teaching (35.4% vs 65.2%, p-value < 0.001), osteoporosis screening (20.8% vs 44.9%, p-value < 0.001) and influenza vaccination (74.3% vs 83.5%, p-value = 0.03) in post intervention period.

CONCLUSIONS

Implementation of a standardized COPD Flowsheet developed from clinical practice guidelines improves advanced assessment of patients with COPD and other quality of care measures.

Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews

OBJECTIVES

Translating research evidence into routine clinical practice is notoriously difficult. Behavioural interventions are often used to change practice, although their success is variable and the characteristics of more successful interventions are unclear. We aimed to establish the characteristics of successful behaviour change interventions in healthcare.

DESIGN

We carried out a systematic overview of systematic reviews on the effectiveness of behaviour change interventions with a theory-led analysis using the constructs of normalisation process theory (NPT). MEDLINE, CINAHL, PsychINFO and the Cochrane Library were searched electronically from inception to July 2015.

SETTING

Primary and secondary care.

PARTICIPANTS

Participants were any patients and healthcare professionals in systematic reviews who met the inclusion criteria of having examined the effectiveness of professional interventions in improving professional practice and/or patient outcomes.

INTERVENTIONS

Professional interventions as defined by the Cochrane Effective Practice and Organisation of Care Review Group.

PRIMARY AND SECONDARY OUTCOME MEASURES

Success of each intervention in changing practice or patient outcomes, and their mechanisms of action. Reviews were coded as to the interventions included, how successful they had been and which NPT constructs its component interventions covered.

RESULTS

Searches identified 4724 articles, 67 of which met the inclusion criteria. Interventions fell into three main categories: persuasive; educational and informational; and action and monitoring. Interventions focusing on action or education (eg, Audit and Feedback, Reminders, Educational Outreach) acted on the NPT constructs of Collective Action and Reflexive Monitoring, and reviews using them tended to report more positive outcomes.

CONCLUSIONS

This theory-led analysis suggests that interventions which contribute to normative restructuring of practice, modifying peer group norms and expectations (eg, educational outreach) and relational restructuring, reinforcing modified peer group norms by emphasising the expectations of an external reference group (eg, Reminders, Audit and Feedback), offer the best chances of success. Combining such interventions is most likely to change behaviour.

How to study improvement interventions: a brief overview of possible study types

Improvement (defined broadly as purposive efforts to secure positive change) has become an increasingly important activity and field of inquiry within healthcare. This article offers an overview of possible methods for the study of improvement interventions. The choice of available designs is wide, but debates continue about how far improvement efforts can be simultaneously practical (aimed at producing change) and scientific (aimed at producing new knowledge), and whether the distinction between the practical and the scientific is a real and useful one. Quality improvement projects tend to be applied and, in some senses, self-evaluating. They are not necessarily directed at generating new knowledge, but reports of such projects if well conducted and cautious in their inferences may be of considerable value. They can be distinguished heuristically from research studies, which are motivated by and set out explicitly to test a hypothesis, or otherwise generate new knowledge, and from formal evaluations of improvement projects. We discuss variants of trial designs, quasi-experimental designs, systematic reviews, programme evaluations, process evaluations, qualitative studies, and economic evaluations. We note that designs that are better suited to the evaluation of clearly defined and static interventions may be adopted without giving sufficient attention to the challenges associated with the dynamic nature of improvement interventions and their interactions with contextual factors. Reconciling pragmatism and research rigour is highly desirable in the study of improvement. Trade-offs need to be made wisely, taking into account the objectives involved and inferences to be made.

Reduction in the incidence of pressure ulcers upon implementation of a reminder system for health-care providers

PURPOSE

To measure the clinical impact of the introduction of a reminder system for healthcare professionals to alert patients who are at risk for pressure ulcers (PU).

METHODS

This was a pre- and post-test study of patients who were discharged from 6 medical-surgical units of the University Hospital of Fuenlabrada in 2009 and 2010. Beginning in January 2010, implementation of an on-screen list of reminders was automatically updated daily on the units' computers including patient arrival date, last assessment of ulceration risk and location of any PU. The cumulative incidence of PU was measured for patients discharged in 2009 (group A: healthcare professionals were not exposed to on-screen reminder) and 2010 (group B: healthcare professionals were exposed to on-screen reminder list). The relative risk (RR) was estimated. The study was completed with a stratified analysis and binary logistic regression.

RESULTS

In group A, there were 84 cases of PU among 9263 patients discharged (0.9%); whereas in group B, there were 59 cases among 9220 patients discharged (0.6%). The RR of PU for group B/group A was 0.706 (p=0.038). In the logistic regression analysis, after adjusting for study variables, the odds ratio of PU B/A was 0.558.

CONCLUSION

A list of on-screen reminders at the beginning of a healthcare professional's shift to inform them of patients at risk for developing a PU was effective at reducing the incidence of these clinical burdens.

Impacts of information and communication technologies on nursing care: an overview of systematic reviews (protocol)

BACKGROUND

Information and communication technologies (ICTs) used in the health sector have well-known advantages. They can promote patient-centered healthcare, improve quality of care, and educate health professionals and patients. However, implementation of ICTs remains difficult and involves changes at different levels: patients, healthcare providers, and healthcare organizations. Nurses constitute the largest health provider group of the healthcare workforce. The use of ICTs by nurses can have impacts in their practice. The main objective of this review of systematic reviews is to systematically summarize the best evidence regarding the effects of ICTs on nursing care.

METHODS/DESIGN

We will include all types of reviews that aim to evaluate the influence of ICTs used by nurses on nursing care. We will consider four types of ICTs used by nurses as a way to provide healthcare: management systems, communication systems, information systems, and computerized decision support systems. We will exclude nursing management systems, educational systems, and telephone systems. The following types of comparisons will be carried out: ICT in comparison with usual care/practice, ICT compared to any other ICT, and ICT versus other types of interventions. The primary outcomes will include nurses' practice environment, nursing processes/scope of nursing practice, nurses' professional satisfaction as well as nursing sensitive outcomes, such as patient safety, comfort, and quality of life related to care, empowerment, functional status, satisfaction, and patient experience. Secondary outcomes will include satisfaction with ICT from the nurses and patients' perspective. Reviews published in English, French, or Spanish from 1 January 1995 will be considered. Two reviewers will independently screen the title and abstract of the papers in order to assess their eligibility and extract the following information: characteristics of the population and setting, type of interventions (e.g., type of ICTs and service provided), comparisons, outcomes, and review limitations. Any disagreements will be resolved by discussion and consensus involving the two reviewers or will involve a third review author, if needed.

DISCUSSION

This overview is an interesting starting point from which to compare and contrast findings of separate reviews regarding the positive and negative effects of ICTs on nursing care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014762.