Continuing education meetings and workshops: effects on professional practice and health care outcomes

Continuing Professional Development (CPD) and Vocational Education and Training (VET) in Periodontology and Implant Dentistry

AIM

To (i) evaluate structured postgraduate part-time programs in periodontology, including those addressing peri-implant diseases, among members of the European Federation of Periodontology (EFP), (ii) the impact of the 2018 classification scheme and EFP clinical practice guidelines and (iii) propose a framework for periodontal vocational education and training.

MATERIALS AND METHODS

A summary of relevant European guidelines for vocational education and training was compiled. In a survey and in a systematic review, current part-time programs in continuing professional education in periodontology as well as in prevention and management of peri-implant diseases were examined. The implementation and dissemination of the 2018 classification scheme and the EFP clinical practice guidelines were assessed by literature analysis. Based on these findings, a framework for periodontal vocational education and training was generated.

RESULTS

Part-time programs for professional development in periodontology are established in nine EFP member countries. The systematic review identified lack of knowledge in prevention and management of peri-implant diseases among dental practitioners and hygienists. Continuing professional development was found to be important for education in prevention, classification and management of periodontal as well as peri-implant diseases. The proposed European framework consists of an escalator model with three levels (certificate, diploma and master).

DISCUSSION

Considering the identified variation in the national programs, there is a need to improve education in periodontal and peri-implant diseases. The proposed frameworkmay will help harmonize the national structures.

CONCLUSION

The proposed framework for part-time professional development is expected to enhance professional qualification.

Assessment of the Implementation of Global Initiative for Asthma (GINA) 2019 Guidelines for Treatment of Mild Asthma Among Pediatric Registrars: A Quasi-Interventional Study

Background and Aims

It is essential to have proper treatment and management for asthma in order to minimise symptoms, lessen the burden, and lower the chance of exacerbations. To better control asthma, the purpose of this study was to evaluate and enhance paediatric registrars' understanding and application of asthma treatment.

Methods

The Sudan Medical Specialisation Board (SMSB) paediatric registrars provided data for this quasi-interventional study between April and September of 2021. Twice, both before to and following the intervention education sessions, the questionnaire was delivered. SPSS version 28 was used to analyse the data after it had been cleaned up in an Excel document.

Results

203 (or 77.8%) of the 261 were women. A substantial rise from 8.1 ± 4.12 SD to 18 ± 5.03 SD in the mean overall knowledge score of registrars between the pre-and post-intervention periods. A significant difference (p=0.001) was observed in the post-intervention phase, with first-year registrars (R1) demonstrating higher scores than their senior colleagues. The registrars' total knowledge scores did not differ significantly from one another during the pre-intervention period. The Global Initiative of Asthma (GINA) guidelines of management were implemented to a certain extent, according to the study. Of the registrars, 148 (56.7%) and 203 (77.8%) evaluated step one management in children ages 5 and under; 66 (25.3%) and 213 (81.6%) evaluated step one management in children ages 6 to 11; and 66 (25.3%) and 213 (81.6%) evaluated step one management in children ages 6 to 11 in pre- and post-intervention, respectively.

Conclusion

Given that the intervention in this study greatly increased registrars' knowledge, doctors should obtain training on the GINA 2019 recommendations through conferences, workshops, and academic programmes. To find out why R1 outperforms their older counterparts, more investigation has to be done.

Optimizing Contraceptive Prescription in Smoking Women: A Quality Improvement Study

Introduction Family planning is fundamental in primary care (PC), and informed counseling helps to guide contraceptive choices. Combined hormonal contraceptives (CHC) pose cardiovascular risks, particularly when combined with smoking. According to the World Health Organization, the recommended global clinical decision is to refrain from employing CHC in female smokers aged 35 or older. This study aimed to improve contraception prescription for female smokers aged 35-54 in PC. Methods This study was conducted in a Portuguese Family Health Unit (FHU) from October 2021 to August 2022, and it followed the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines and the Plan-Do-Study-Act approach. Female smokers aged 35-54 were included and evaluated in three moments: baseline evaluation (October 2021), intermediate evaluation (February 2022), and post-intervention evaluation (August 2022). Interventions involved educating medical staff, creating patient awareness campaigns, and evaluating contraceptive methods. The established quality-defining goal was to decrease the prevalence of female smokers aged 35 or above using CHC to ≤5%. Results CHC prevalence among smoking women aged 35-54 decreased from 16.4% to 8.5% after nine months of the initial intervention. There was an increase in progestogen-only methods usage over time, from 25.7% to 34.0%. Discussion Despite not fully achieving the predefined goal, interventions led to a substantial reduction of CHC use among smoking women aged 35-54. Collaborative efforts between healthcare professionals and patients played a pivotal role in optimizing care and reducing cardiovascular risk. This study underscores the importance of continuous quality improvement, collaborative interventions, and knowledge updates in Family Medicine practice. While conducted in a single FHU, the intervention's multidimensional approach holds the potential for broader applicability. Conclusion In the future, healthcare teams should continue to reflect on achieved results, maintain knowledge, and empower patients in contraceptive method choices. The study contributes to improved care quality and highlights the positive impact on medical practice and patient outcomes.

Understanding professional development challenges of Chinese public health professionals: association and prediction analyses with data validity screening

Background

Little is known about the public health professionals engaged in educating and training new or future researchers in public health. Research in this direction identifies their issues, concerns, challenges, and needs. This study focused on the professional development challenges of Chinese public health professionals.

Methods

Snowball sampling was utilized. A total of 265 public health professionals participated. An instrument of 6 dimensions (burnout, sleep issue, mood issue, friends' support, exercise, and challenges) was developed, revised, and administered online. Two different approaches, the conventional and data screening approaches, were applied. The former started with item quality analyses, whereas the latter began with data quality checks. The chi-square tests of associations and logistic regressions were performed on both approaches.

Results and discussion

19.25% of the participants were detected and deleted as careless respondents. Using both approaches, six professional development challenges except one ("Multidisciplinary learning") were significantly associated with various demographic features. The two approaches produced different models though they converged sometimes. The latent variables of exercise predicted professional development challenges more frequently than other latent variables. Regarding correct classification rates, results from the data screening approach were comparable to those from the conventional approach.

Conclusion

The latent variables of exercise, such as "Exercise effects," "Expectations of exercise," and "Belief in exercise," might be understudied. More research is necessary for professional development challenges using exercise as a multidimensional construct. Based on the current study, screening and deleting careless responses in survey research is necessary.

LGBTQ + cultural competency training for health professionals: a systematic review

BACKGROUND

Health disparities experienced by LGBTQ + individuals have been partially attributed to health professionals' lack of cultural competence to work with them. Cultural competence, the intricate integration of knowledge, skills, attitudes, and behaviors that improve cross-cultural communication and interpersonal relationships, has been used as a training framework to enhance interactions between LGBTQ + patients and health professionals. Despite multiple published LGBTQ + cultural competency trainings, there has been no quantitative appraisal and synthesis of them. This systematic review assessed articles evaluating the design and effectiveness of these trainings and examined the magnitude of their effect on cultural competence outcomes.

METHODS

Included studies quantitatively examined the effectiveness of LGBTQ + cultural competency trainings for health professionals across all disciplines in various healthcare settings. 2,069 citations were retrieved from five electronic databases with 44 articles meeting inclusion criteria. The risk of bias in the included studies was assessed by two authors utilizing the Joanna Briggs Institute critical appraisal checklists. Data extracted included study design, country/region, sample characteristic, training setting, theoretical framework, training topic, modality, duration, trainer, training target, measurement instrument, effect size and key findings. This review followed the PRISMA statement and checklist to ensure proper reporting.

RESULTS

75% of the studies were published between 2017 and 2023. Four study designs were used: randomized controlled trial (n = 1), quasi-experimental pretest-posttest without control (n = 39), posttest only with control (n = 1) and posttest only without control (n = 3). Training modalities were multiple modalities with (n = 9) and without simulation (n = 25); single modality with simulation (n = 1); and with didactic lectures (n = 9). Trainings averaged 3.2 h. Ten studies employed LGBTQ + trainers. The training sessions resulted in statistically significant improvements in the following cultural competence constructs: (1) knowledge of LGBTQ + culture and health (n = 28, effect size range = 0.28 - 1.49), (2) skills to work with LGBTQ + clients (n = 8, effect size range = 0.12 - 1.12), (3) attitudes toward LGBTQ + individuals (n = 14, effect size range = 0.19 - 1.03), and (4) behaviors toward LGBTQ + affirming practices (n = 7, effect size range = 0.51 - 1.11).

CONCLUSIONS

The findings of this review highlight the potential of LGBTQ + cultural competency training to enhance cultural competence constructs, including (1) knowledge of LGBTQ + culture and health, (2) skills to work with LGBTQ + clients, (3) attitudes toward LGBTQ + individuals, and (4) behaviors toward LGBTQ + affirming practices, through an interdisciplinary and multi-modal approach. Despite the promising results of LGBTQ + cultural competency training in improving health professionals' cultural competence, there are limitations in study designs, sample sizes, theoretical framing, and the absence of longitudinal assessments and patient-reported outcomes, which call for more rigorous research. Moreover, the increasing number of state and federal policies that restrict LGBTQ + health services highlight the urgency of equipping health professionals with culturally responsive training. Organizations and health systems must prioritize organizational-level changes that support LGBTQ + inclusive practices to provide access to safe and affirming healthcare services for LGBTQ + individuals.

Continuing Pharmacy Education: Exploring the Status and Future Prospects in Nepal

Continuing pharmacy education (CPE) is an educational way for pharmacy professionals to develop competency in providing quality pharmaceutical care to patients. The CPE program helps maintain up-to-date knowledge and skills, increase the professionalism of pharmacists, and positively impact patient health outcomes. However, the concept and practice of CPE are still in their infancy in Nepal. Nepal's conventional pharmacy education system involves didactic lectures focusing more on theoretical learning than practical and experiential approaches, leading to the generation of pharmacists theoretically knowledgeable but practically non-competent to deliver pharmaceutical care services in independent practice settings. Additionally, in the absence of CPE, the professionals might miss updated information on new therapies, technologies, and approaches in patient management. The community and hospital pharmacies in Nepal are often business-oriented rather than service, and may not even be staffed by pharmacists, so the CPE programs are rarely conducted for the pharmacy professionals. Hence, the present commentary aimed to explore the status of CPE and its barriers or challenges in implementation and to suggest solutions in Nepal.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Medication safety in primary care-from measurement to action

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Promoting oral health in nursing education through interprofessional collaborative practice: A quasi-experimental survey study design

BACKGROUND

Optimal oral health education is limited in nursing curricula and may therefore, not translate as a priority for nurses in clinical practice.

OBJECTIVES

To evaluate the influence of an educational intervention on knowledge, confidence, practice behaviors, and perceived barriers of nursing students regarding preventive oral health services.

DESIGN

Quasi-experimental pre-post survey study design.

PARTICIPANTS

Sixty-four first-year Accelerated Bachelor of Nursing (ASBN) students at the University of North Carolina at Chapel Hill.

METHODS

Students were asked to complete oral-health-related questionnaires following didactic and clinical simulation on principles of oral health, oral screening, counseling, and referral to a dentist. A post-survey following clinical rotations was completed testing long-term effectiveness.

RESULTS

Fifty-five (86%) ABSN students completed the pre-survey, 49 (77%) completed the post-survey; 44 (69%) completed both. Participants' showed a significant increase in knowledge from pre-post questionnaires for two of five questions (p = 0.04; p < 0.0001). Confidence scores in performing oral screenings (p < 0.0001) and counseling (p = 0.006) increased; while scores regarding referrals decreased (p = 0.718). Post-intervention, 37% reported performing oral screenings, 45% counseling, and 8% dental referrals. Respondents reported a significant increase in willingness to implement oral health services during clinical visits (p < 0.0001).

CONCLUSION

Mixed educational methods can successfully influence oral health knowledge and confidence among ABSN students and their willingness to perform in clinical practice.

Does Continuing Medical Education (CME) Activity Contribute to Learning Gain: An Objective Evaluation

Continuing medical education (CME) and work-shops go a long way to update and refresh medical education of the medical practitioners and help them to stay updated about latest advances in the medical field which helps them to impart latest and better treatment to the patients. This article aims at reporting the evaluation of the effectiveness of the learning in terms of knowledge gained immediately after the workshop and to objectively quantify the knowledge gain from the CME program. Pre- and post-CME survey of knowledge by the way of multiple choice question questionnaire was used to assess the efficacy of the CME and the learning gain of the participants. 42 participants were included in the assessment of the gain in knowledge after the CME. An increase of 17.9% in the scores of the participants was seen at the end of the CME, with a learning gain of 38%. Educational activity like CME can improve the knowledge base of the intended participants. Further research is required to evaluate if education delivered in a short workshop of this nature is retained for any length of time and if it results in any change in practice that affects health outcomes.

Evaluating knowledge, skills, and practice change after an accredited evidence-based medicine course for community pharmacy preceptors

INTRODUCTION

Incorporating evidence-based medicine skills into practice is vital for pharmacists to promote rational medication use while making optimal patient care decisions. The objective of this study was to evaluate the impact of an evidence-based medicine course on the knowledge and precepting skills of community pharmacy preceptors.

METHODS

This was a longitudinal, multiphase, interventional study, which involved the development of an evidence-based medicine course based on results of an educational assessment. The course was delivered over five sessions and included didactic and active learning strategies. The impact was measured by the preceptor's ability to apply knowledge gained from the course while providing student feedback during a community practice experience using a journal club context.

RESULTS

Ten preceptors completed the course with 50% and 70% passing the drug information and critical appraisal assessments, respectively. When measuring course impact, 44% of preceptors were able to provide feedback at a proficient level while 56% needed further development. Preceptors' confidence improved across pre-course, post-course, and after the observation phase in interpreting study results (p = 0.016), teaching the student evidence-based medicine skills (p = 0.008), and providing feedback to the student regarding journal clubs (p = 0.010). Students rated high improvement in the preceptor's ability to provide feedback related to critical appraisal skills.

CONCLUSION

A course-based approach to increase preceptor's knowledge of critical appraisal and drug information skills may be effective.

Possibilities for interprofessional learning at a Swedish acute healthcare ward not dedicated to interprofessional education: an ethnographic study

OBJECTIVES

Almost all healthcare today is team-based in collaboration over professional borders, and numerous students have work-based learning in such contexts. However, interprofessional learning (IPL) in clinical settings has mostly been systematically explored in specially designed contexts dedicated to interprofessional education (IPE). This study aimed to explore the possibilities for IPL activities, and if or how they occur, in an acute ward context not dedicated to IPE.

DESIGN AND SETTING

Between 2011 and 2013 ethnographic observations were performed of medical and nursing students' interactions and IPL during early clerkship at an acute internal medicine ward in Sweden. Field notes were taken and analysed based on the framework of IPE: learning with, from and about.

PARTICIPANTS

21 medical, 4 nursing students and 30 supervisors participated.

RESULTS

Learning with-there were no organised IPE activities. Instead, medical and nursing students learnt in parallel. However, students interacted with staff members from other professions. Learning from-interprofessional supervision was frequent. Interprofessional supervision of nursing students by doctors focused on theoretical questions and answers, while interprofessional supervision of medical students by nurses focused on the performance of technical skills. Learning about-students were observed to actively observe interactions between staff and learnt how staff conducted different tasks.

CONCLUSION

This study shows that there were plenty of possibilities for IPL activities, but the potential was not fully utilised or facilitated. Serendipitous IPL activities differed between observed medical and nursing students. Although interprofessional supervision was fairly frequent, students were not learning with, from or about each other over professional borders.

Fixation of ankle fractures - a major trauma centre's experience in improving quality

BACKGROUND

Ankle fracture malreduction has been shown to result in poor long-term functional outcomes. Varying methods can be used to change practice and thereby outcomes. We present over four years' worth of results with the effects of different techniques for change.

METHODS

Two audit cycles were performed incorporating three audit data collections; an initial standard setting audit in 2013, with re-audits in 2015 and 2017. Between the first and second audit was a period of education and reflection. Between the second and third audit there was a change in process in ankle fracture management supported by education. Image intensifier films were reviewed on the hospital picture archiving and communication system, by at least two blinded observers in each cycle. These were scored based on the criteria published by Pettrone et al.

RESULTS

In the initial audit in 2013, there were 94 patients, with a malreduction rate of 33%. In the second audit in 2015, there were 68 patients, with an increase in malreduction rate to 43.8%. In the third audit in 2017, there were 205 patients, with a significant decrease in malreduction rate to 2.4%. The final major complication rate was 0.98%. The rate of deep infection was 0.5%.

CONCLUSIONS

By recognising and addressing the need to improve the quality of ankle fracture fixation, we have made significant improvements in radiological outcomes. Education alone, without system change, was not successful in our department in achieving improved outcomes.

An Educational Intervention to Improve Statin Use: Cluster RCT at the Primary Care Level in Argentina

INTRODUCTION

Statins are essential drugs for high cardiovascular disease (CVD) risk management; however, there is still low adherence to good clinical practice guidelines for statin use at the primary care level in low- and middle-income countries. This study aimed to test whether a complex intervention targeting physicians improves treatment and control of hypercholesterolemia among patients with moderate to high CVD risk in Argentina.

STUDY DESIGN

Cluster RCT.

SETTING/PARTICIPANTS

Ten primary care centers from the public healthcare system of Argentina.

INTERVENTION

Primary care physicians in the intervention group received an educational program with three main components: (1) an intensive 2-day training workshop; (2) educational outreach visits; and (3) a mobile health application installed on the physician's smartphones.

MAIN OUTCOME MEASURES

Reduction in mean low-density lipoprotein cholesterol level, reduction in mean Framingham risk score, proportion of patients receiving an appropriate statin dose, and mean annual number of primary care center visits.

RESULTS

Data were analyzed in 2017-2018. Between April 2015 and April 2016, a total of 357 participants were enrolled (179 patients in the intervention group and 178 in the control group). The global follow-up rate was 97.2%. At the end of the follow-up period, there was no difference in low-density lipoprotein cholesterol levels in any of the follow-up points among the groups. Mean CVD risk had a significant net difference in the first 6 months in the intervention group versus the control group (-4.0, 95% CI = -6.5, -1.5). At the end of follow-up, there was an absolute 41.5% higher rate of participants receiving an appropriate statin dose in the intervention group versus the control group.

CONCLUSIONS

Although the intervention did not reach a reduction in cholesterol levels, it had a significant positive impact on the promotion of adequate use of clinical practice guidelines.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02380911.

Evaluating shared decision-making in periviable counseling using objective structured clinical examinations

OBJECTIVE

To develop and test an Objective Structured Clinical Examination to evaluate the use of shared decision-making (SDM) in periviable counseling among fourth-year OB/GYN residents.

METHODS

Residents counseled a standardized patient presenting with preterm premature rupture of membranes at 23 weeks' gestation. Braddock's 9-item measure of SDM was adapted to a 10-item scoring rubric; rating each: 0 (absent), 1 (partial), or 2 (complete).

RESULTS

Twenty-six residents participated. All provided "complete" discussions of the clinical issue and "complete" or 'partial' ratings for informing the woman of her prognosis (62 and 38%, respectively) and addressing her role in decision-making (42 and 50%). Discussions of her goals and preferences were often absent (69 and 62%). Only 42% discussed uncertainties.

CONCLUSION

Critical elements of SDM related to a woman's values, goals and preferences were not explored when counseling about periviable delivery. Training in SDM is needed to advance communication skills for complex clinical decision-making.

Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units

Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.

Continuing Education and New Zealand Anaesthetists: An Analysis of Current Practice and Future Needs

A survey of Continuing Medical Education (CME) of New Zealand anaesthetists was undertaken to identify current patterns of participation, usefulness of different activities, evidence of effectiveness, motivators and barriers to participation and to define future CME needs.

The response rate was 74% and showed high levels of participation in a range of CME activities. Ratings for usefulness differed significantly between these activities. Respondents identified specific changes they had made to their practice as a result of CME, providing strong evidence for its effectiveness.

Anaesthetists valued interactive methods of learning that were relevant to clinical practice. The most commonly reported motivators for participation were accreditation requirements and keeping up to date, while other work commitments were the commonest impediment. In this survey, interactive educational interventions were seen as useful, a finding consistent with systematic reviews of the effectiveness of CME in changing physician behaviour. Such reviews conclude that there is no evidence that conferences are effective in changing physician behaviour, yet respondents to this survey attributed many changes in practice to their attendance at a conference.

Analysis of the needs of NZ anaesthetists supports increasing the number of workshops and interactive sessions and promoting smaller meetings and practice-based activities. The survey provides a basis for designing a future program of CME for New Zealand.

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.

Reasons for and Barriers to Attending Continuing Education Activities and Priorities for Different Dental Specialties

BACKGROUND

Continuing education (CE) activities help dentists update their knowledge and skills to ensure high standards of patient care.

AIM

This study aimed to evaluate the reasons for and barriers to attending CE activities including the priorities for different dental specialities.

METHODS

The study involves a cross-sectional research design. After statistical consultation, a questionnaire was distributed among 323 dental practitioners in the Eastern province of Saudi Arabia. The questionnaire was checked for face and content validity, and it was pilot-tested before its administration.

RESULTS

The response rate was 79.5% as 257 of 323 dentists returned the questionnaire. Most dentists reported that they attended CE activities because of personal learning needs (67.3%) and career development (66.9%). Lack of clinical experience to effectively manage patients and the practice was the least common (15.2%) reason for attending CE activities. Esthetic dentistry (77.4%), restorative dentistry (70.8%), and endodontics (70%) were the three most preferred dental specialities for CE activities. Lack of time was the most common (69.3%) barrier to attending CE activities followed by the cost (62.6%) and the distance (57.2%). More male (n = 104) than female (n = 69) dentists believed personal learning needs a reason for attending CE activities (P = 0.01). Similarly, more male (n = 104) than female dentists (n = 68) considered lack of time a barrier (P = 0.046).

CONCLUSION

Most dentists attended CE activities to fulfil their personal learning needs, and aesthetic dentistry was the most preferred dental speciality for CE activities. Lack of time and cost were important barriers to attending CE activities.

Opinion of hospital pharmacy practitioners toward the Continuing Pharmacy Education program: a study from a tertiary care hospital in central Nepal

Background

Meeting participants’ needs and matching their preferences are important prerequisites for an effective Continuing Pharmacy Education (CPE) program. The objective of this pilot study was to assess the opinion of hospital pharmacy practitioners with respect to the CPE program.

Methods

The pretested questionnaires were distributed to 20 pharmacy practitioners working in a pharmacy at a tertiary care hospital in Nepal which asked for their opinions and suggestions with respect to the CPE program. Descriptive statistics were performed using IBM SPSS version 20.

Results

Topics related to skills development (75%) and recent innovations in pharmacy practice (65%) were mostly preferred. Live (in-person) presentations (80%) and small group discussion (60%) were the most suitable methods for delivery. Improving knowledge (75%), improving skills (60%) and keeping up-to-date in the latest information (60%) were major motivating factors to participate, while lack of time (75%) was a major barrier. Approximately 55% of the participants believed that face-to-face interview was a suitable method for evaluating the effectiveness. Allocation of separate time for the program, assessing baseline knowledge and skills of the participants along with delivery of quality materials in an understandable way were the top common suggestions for improving the CPE program.

Conclusion

Hospital pharmacy practitioners’ opinions and suggestions were assessed with respect to the CPE program and this was upgraded accordingly to meet their expectations.

A cluster randomised controlled trial of a staff-training intervention in residential units for people with long-term mental illness in Portugal: the PromQual trial

PURPOSE

This study aimed to assess the efficacy of a staff-training intervention to improve service users' engagement in activities and quality of care, by means of a cluster randomised controlled trial.

METHOD

All residential units with at least 12-h a day staff support (n = 23) were invited to participate. Quality of care was assessed with the Quality Indicator for Rehabilitative Care (QuIRC) filled online by the unit's manager. Half the units (n = 12) were randomly assigned to continue providing treatment as usual, and half (n = 11) received a staff-training intervention that focused on skills for engaging service users in activities, with trainers working alongside staff to embed this learning in the service. The primary outcome was service users' level of activity (measured with the Time Use Diary), reassessed at 4 and 8 months. Secondary outcomes were the quality of care provided (QuIRC), and service users' quality of life (Manchester Short Assessment of Quality of Life) reassessed at 8 months. Generalized linear mixed effect models were used to assess the difference in outcomes between units in the two trial arms. The trial was registered with Current Controlled Trials (Ref NCT02366117).

RESULTS

Knowledge acquired by the staff during the initial workshops increased significantly (p ≤ 0.01). However, the intervention and comparison units did not differ significantly in primary and secondary outcomes at either follow-up.

CONCLUSIONS

The intervention increased the level of knowledge of staff without leading to an improvement in service users' engagement in activities, quality of life, or quality of care in the units.

Understanding the dissemination of appointment-based synchronization models using the CFIR framework

BACKGROUND

The appointment based model (ABM) is a innovative model of pharmacy practice that combines medication synchronization with scheduled monthly appointments to improve patient medication adherence and convenience. It is being implemented in many pharmacies across the United States.

OBJECTIVE

The purpose of this article is to use the Consolidated Framework for Implementation Research (CFIR) to discuss the barriers and facilitators of ABM implementation in community pharmacies while identifying priorities for additional implementation research.

METHODS

A review of current evidence of ABM was examined using the five domains within the CFIR taxonomy. Interactions between these domains (the intervention, the individuals involved, the process used to implement the intervention, the inner setting, and the outer setting) and their sub domains were used to explain the current success of ABM and future barriers.

RESULTS

The CFIR is an effective theoretical framework for assessing ABM. It helps identify key constructs in ABM implementation and their relationships. It also suggests future research to facilitate its adoption as a standard of pharmacy practice.

CONCLUSIONS

The adoption of ABM by pharmacies will be facilitated by better evidence of its clinical and economic impact on patient health outcomes, standardization of ABM, and integrating it into current workflows.

Assessing and enhancing quality through outcomes-based continuing professional development (CPD): a review of current practice

Numerous professional bodies have questioned whether traditional input-based continuing professional development (CPD) schemes are effective at measuring genuine learning and improving practice performance and patient health. The most commonly used type of long-established CPD activities, such as conferences, lectures and symposia, have been found to have a limited effect on improving practitioner competence and performance, and no significant effect on patient health outcomes. Additionally, it is thought that the impact of many CPD activities is reduced when they are undertaken in isolation outside of a defined structure of directed learning. In contrast, CPD activities which are interactive, encourage reflection on practice, provide opportunities to practice skills, involve multiple exposures, help practitioners to identify between current performance and a standard to be achieved, and are focused on outcomes, are the most effective at improving practice and patient health outcomes.

Applying Research Evidence to Practice

One of the important factors in the process of clinical governance is the use of research evidence to inform practice. However, it is not enough to search for and appraise research evidence. Once the information has been appraised, it may be necessary to change practice in order to implement the knowledge.

This paper considers the responsibility of occupational therapists to address this change. It is widely accepted that it is notoriously difficult to bring about change in established professional practice. Strategies to help to effect change in practice are discussed and recent research regarding the most effective strategies is considered. The value of combined strategies, including continuing education, clinical guidelines and opinion leaders, is addressed.

Comparing and improving chronic illness primary care in Sweden and the USA

Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible explanations for differences and practical improvements by comparing the two countries. Many enhancements are low cost and the proportionate reduction in suffering and costs they bring is high.

Knowledge and use of asthma control measurement tools in the management of asthma: a survey of doctors working in family and internal medicine practice in Nigeria

OBJECTIVE

To investigate the knowledge and use of asthma control measurement (ACM) tools in the management of asthma among doctors working in family and internal medicine practice in Nigeria.

METHOD

A questionnaire based on the global initiative on asthma (GINA) guideline was self-administered by 194 doctors. It contains 12 test items on knowledge of ACM tools and its application. The knowledge score was obtained by adding the correct answers and classified as good if the score ≥ 9, satisfactory if score was 6-8 and poor if < 6.

RESULTS

The overall doctors knowledge score of ACM tools was 4.49±2.14 (maximum of 12). Pulmonologists recorded the highest knowledge score of 10.75±1.85. The majority (69.6%) had poor knowledge score of ACM tools. Fifty (25.8%) assessed their patients' level of asthma control and 34(17.5%) at every visit. Thirty-nine (20.1%) used ACM tools in their consultation, 29 (15.0%) of them used GINA defined control while 10 (5.2 %) used asthma control test (ACT). The use of the tools was associated with pulmonologists, having attended CME within six months and graduated within five years prior to the survey.

CONCLUSION

The results highlight the poor knowledge and use of ACM tools and the need to address the knowledge gap.

Effectiveness of a nurse educational oral feeding programme on feeding outcomes in neonates: protocol for an interrupted time series design

INTRODUCTION

Oral feeding is a complex physiological process. Several scales have been developed to assess the ability of the neonate to begin suck feedings and assist caregivers in determining feeding advancement. However, feeding premature neonates remains an ongoing challenge and depends above all on caregivers' feeding expertise. We will evaluate the effect of a nurse training programme on the achievement of full oral feeding with premature neonates.

METHODS AND ANALYSIS

The study design will be an interrupted time series design with 3 phases: (1) A 6-month baseline period; (2) a 22-month intervention period and (3) a 6-month postintervention period. The intervention will consist of an educational programme, for nurses and assistant nurses, on feeding patterns in neonates. The training modules will be composed of a 2-day conference, 2 interactive multidisciplinary workshops, and routine practice nurse coaching. A total of 120 nurses and 12 assistant nurses, who work at the neonatal unit during the study period, will participate in the study. All premature neonates of <34 weeks postmenstrual age (PMA) will be included. The primary outcome will be the age of tube withdrawal PMA and chronological age are taken into account. The secondary outcomes will be the transition time, length of hospital stay, competent suckle feeding without cardiorespiratory compromise, rate of neonates presenting with feeding issues or feeding rejection signs, and current neonatal pathologies or deaths during hospital stay. A segmented regression analysis will be performed to assess the impact of the programme.

ETHICS AND DISSEMINATION

Approval for the study was obtained from the Hospital Ethics Committee, and the Institutional Review Board, as well as the French Data Protection Agency. The findings from the study will be disseminated through peer-reviewed journals, national and international conference presentations and public events.

TRIAL REGISTRATION NUMBER

NCT02404272 (https://clinicaltrials.gov).

Maintaining prostate contouring consistency following an educational intervention

Introduction

The aim of this study was to assess variation in prostate contouring 12 months following a structured interactive educational intervention (EI) and to test the hypothesis that EIs positively impact on prostate contouring accuracy and consistency long term.

Methods

A common set of computed tomography (CT) and magnetic resonance imaging (MRI) data sets were used to assess prostate contouring consistency before, immediately after and 12 months following an EI. No further EIs were provided after the initial EI. Contour variation was assessed using the volume ratio (VR), defined as the ratio of the encompassing volume to common volume.

Results

Of the original five radiation oncologists (ROs) at baseline, four completed all assessments, and one was unavailable at 12 months follow‐up. At 12 months, mean VR deteriorated by 3.2% on CT and 1.9% on MRI compared to immediately post EI. Overall, compared to the pre‐EI baseline VR, an improvement of 11.4% and 10.8% was demonstrated on CT and MRI, respectively.

Conclusion

Good retention of applied knowledge 12 months following an EI on prostate contouring was demonstrated. This study advocates for EIs to be included as part of continuing medical education to reduce contour variation among ROs and improve knowledge retention long term.

Linking medical faculty stress/burnout to willingness to implement medical school curriculum change: a preliminary investigation

RATIONALE, AIMS AND OBJECTIVES

Balancing administrative demands from the medical school while providing patient support and seeking academic advancement can cause personal hardship that ranges from high stress to clinically recognizable conditions such as burnout. Regarding the importance of clinical faculties' burnout and its effects on different aspects of their professional career, this study was conducted and aimed to evaluate the relationship between willingness to change teaching approaches as characterized by a modified stage-of-change model and measures of stress and burnout.

METHODS

This descriptive analytic study was conducted on 143 clinical faculty members of Tehran University of Medical Sciences in Iran. Participants were asked to complete three questionnaires: a modified stages of change questionnaire the Maslach Burnout Inventory and the General Health Questionnaire. Data were analysed by SPSS: 16 using non-parametric statistical tests such as multiple regression and ICC (intra-class coefficient) and Spearman correlation coefficient test.

RESULT

A significant relationship was found between faculty members' readiness to change teaching approaches and the subscales of occupational burnout. Specifically, participants with low occupational burnout were more likely to be in the action stage, while those with high burnout were in the attitude or intention stage, which could be understood as not being ready to implement change. There was no significant correlation between general health scores and stage of change.

CONCLUSIONS

We found it feasible to measure stages of change as well as stress/burnout in academic doctors. Occupational burnout directly reduces the readiness to change. To have successful academic reform in medical schools, it therefore would be beneficial to assess and manage occupational burnout among clinical faculty members.

Improving confidence and competence of healthcare professionals in end-of-life care: an evaluation of the 'Transforming End of Life Care' course at an acute hospital trust

Background

UK policymakers, clinicians and public wish to see improvements in end-of-life care (EoLC). However, healthcare professionals’ skills and knowledge to deliver high-quality care are often lacking. Since May 2012, palliative care staff in an inner-city tertiary hospital have run a 2-day Transforming End of Life Care (TEoLC) course to improve EoLC confidence, and competence among hospital and community staff.

Aim

To evaluate course participants’ self-rated confidence, competence and knowledge of EoLC topics.

Evaluation design

A before-and-after design using self-completion questionnaires, precourse and postcourse. 14 self-assessment questions examined confidence, understanding and knowledge of EoLC topics. Mean change scores and paired t tests were calculated and free-text responses analysed thematically.

Participants

236 staff members completed the course between May 2012 and April 2014. 42% worked in hospitals and 55% in the community; the most frequent staff roles were qualified nurses (49%), senior nurses (16%) and general practitioners (15%).

Results

All 14 self-assessment topics improved significantly (p<0.001); most improved was ‘understanding and implementing Fast Track discharge’. Qualitative data showed increased knowledge and confidence in EoLC, particularly in communication, commitment to team work and holistic care. Overall, 217 (92%) participants would recommend the course and 215 (98%) indicated it would influence their practice.

Conclusions

The TEoLC course improved participants’ self-rated confidence, competence and knowledge in EoLC. Findings have utility beyond the UK in light of the international policy recommendations to improve the palliative care skills of generalist healthcare providers.

Effect of an educational intervention to improve adverse drug reaction reporting in physicians: a cluster randomized controlled trial

BACKGROUND

The yellow-card scheme continues to be one of the principal methods for signal generation in pharmacovigilance. Nevertheless, under-reporting, one of its disadvantages, delays alert signals and has a negative influence on public health. Educational interventions in pharmacovigilance may have a positive impact on the spontaneous reporting of adverse drug reactions (ADRs).

OBJECTIVES

To assess the duration of the effect and effectiveness of an educational intervention in pharmacovigilance designed to improve ADR reporting in a robust pharmacovigilance system.

METHODS

A spatial, cluster randomized controlled trial was conducted covering all National Health System physicians in the northwest of Spain and targeting those who were actively engaged in clinical practice (n = 7,498). Of these, 2,120 were assigned in three spatial clusters to the intervention group (six hospitals and 138 primary care centers) and 3,614 in four clusters to the control group (seven hospitals and 267 primary care centers). The educational intervention consisted of two complementary approaches--one active (group sessions), the other passive (educational material, reporting form)-implemented from November 2007 to December 2008, with a follow-up period of 8 months.

RESULTS

Intervention participation was 53.7 % in a hospital setting and 60.5 % in primary care settings. ADR reporting in the intervention group increased by 65.4 % (95 % confidence interval [CI]: 8.2-153.4) across the follow-up. The ADR reporting rate per 1,000 physicians/year in the intervention group rose from 28.1 to 39.6 following the intervention (51.7 and 27.4 in the first and second 4-month period, respectively). For the intervention group, relative risk (RR) was 2.31 (95 % CI: 1.46-3.68) and 1.04 (95 % CI: 0.61-1.77) in the first and second 4-month period, respectively adjusted to baseline values. There was an increase in unexpected ADR reporting (RR 2.06, 95 % CI 1.19-3.55).

CONCLUSIONS

Pharmacovigilance educational interventions that have proved effective can be successfully applied in different geographical areas. A high baseline notification rate could account for the educational program having a moderate effect.

A systematic review of professional supervision experiences and effects for allied health practitioners working in non-metropolitan health care settings

Introduction

In regional, rural, and remote settings, allied health professional supervision is one organizational mechanism designed to support and retain the workforce, provide clinical governance, and enhance service delivery. A systematic approach to evaluating the evidence of the experience and effects of professional supervision for non-metropolitan allied health practitioners and their service delivery is needed.

Methods

Studies investigating the experience and effects of professional supervision across 17 allied health disciplines in non-metropolitan health services were systematically searched for using standardized keywords across seven databases. The initial search identified 1,574 references. Of these studies, five met inclusion criteria and were subject to full methodological appraisal by both reviewers. Two studies were primarily qualitative with three studies primarily quantitative in their approach. Studies were appraised using McMaster critical appraisal tools and data were extracted and synthesized.

Results

Studies reported the context specific benefits and challenges of supervision in non-metropolitan areas and the importance of supervision in enhancing satisfaction and support in these areas. Comparison of findings between metropolitan and non-metropolitan settings within one study suggested that allied health in non-metropolitan settings were more satisfied with supervision though less likely to access it and preferred supervision with other non-metropolitan practitioners over access to more experienced supervisors. One study in a regional health service identified the lack of an agreed upon definition and functions of supervision when supervisors from diverse allied health disciplines were surveyed. While methodologically weak, all studies reported positive perceptions of supervision across professionals, supervisors, and managers. This is in accordance with previous research in the wider supervision literature.

Discussion

Considering the large pool of studies retrieved for further investigation, few of these met inclusion criteria demonstrating the paucity of primary research in this area. Increased training, policies, and implementation frameworks to ensure the definition and functions of supervision are agreed upon across the allied health disciplines in non-metropolitan areas is needed. Furthermore, systematic evaluation of supervision implementation in non-metropolitan settings, investigation of the experience and effects of distance based supervision (versus face-to-face), and increased rigor in research studies investigating non-metropolitan allied health profession supervision is needed.

The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews

Background

It is now widely accepted that the mixed effect and success rates of strategies to improve quality and safety in health care are in part due to the different contexts in which the interventions are planned and implemented. The objectives of this study were to (i) describe the reporting of contextual factors in the literature on the effectiveness of quality improvement strategies, (ii) assess the relationship between effectiveness and contextual factors, and (iii) analyse the importance of contextual factors.

Methods

We conducted an umbrella review of systematic reviews searching the following databases: PubMed, Cochrane Database of Systematic Reviews, Embase and CINAHL. The search focused on quality improvement strategies included in the Cochrane Effective Practice and Organisation of Care Group taxonomy. We extracted data on quality improvement effectiveness and context factors. The latter were categorized according to the Model for Understanding Success in Quality tool.

Results

We included 56 systematic reviews in this study of which only 35 described contextual factors related with the effectiveness of quality improvement interventions. The most frequently reported contextual factors were: quality improvement team (n = 12), quality improvement support and capacity (n = 11), organization (n = 9), micro-system (n = 8), and external environment (n = 4). Overall, context factors were poorly reported. Where they were reported, they seem to explain differences in quality improvement effectiveness; however, publication bias may contribute to the observed differences.

Conclusions

Contextual factors may influence the effectiveness of quality improvement interventions, in particular at the level of the clinical micro-system. Future research on the implementation and effectiveness of quality improvement interventions should emphasize formative evaluation to elicit information on context factors and report on them in a more systematic way in order to better appreciate their relative importance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0906-0) contains supplementary material, which is available to authorized users.

Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration

Background

Facilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement.

Methods

We conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators.

Results

The external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach’s role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time.

Conclusions

This study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0252-y) contains supplementary material, which is available to authorized users.

Knowledge and confidence of a convenience sample of australasian emergency doctors in managing dental emergencies: results of a survey

Background. We aimed to determine Australasian Specialist Emergency Physicians' and Emergency Physicians in Training (Trainees') level of knowledge of common dental emergencies. We also explored confidence in managing dental emergencies; predictors of confidence and knowledge; and preferences for further dental education. Methods. A questionnaire was distributed electronically (September 2011) and directly (November 2011) to Fellows and Trainees of the Australasian College for Emergency Medicine. It explored demographics, confidence, knowledge of dental emergencies, and educational preferences. Results. Response rate was 13.6% (464/3405) and college members were proportionally represented by region. Fewer than half (186/446; 42%) had received dental training. Sixty-two percent (244/391, 95% CI 57.5-67.1) passed (>50%) a knowledge test. More than 60% incorrectly answered questions on dental fracture, periodontal abscess, tooth eruption dates, and ulcerative gingivitis. Forty percent (166/416) incorrectly answered a question about Ludwig's Angina. Eighty-three percent (360/433) were confident in the pharmacological management of toothache but only 26% (112/434) confident in recognizing periodontal disease. Knowledge was correlated with confidence (r = 0.488). Interactive workshops were preferred by most (386/415, 93%). Conclusions. The knowledge and confidence of Australasian Emergency Physicians and Trainees in managing dental emergencies are varied, yet correlated. Interactive training sessions in dental emergencies are warranted.

Clinical effectiveness of a staff training intervention in mental health inpatient rehabilitation units designed to increase patients' engagement in activities (the Rehabilitation Effectiveness for Activities for Life [REAL] study): single-blind, cluster-randomised controlled trial

BACKGROUND

Mental health inpatient rehabilitation services focus on people with complex psychosis who have, for example, treatment-refractory symptoms, cognitive impairment, and severe negative symptoms, which impair functioning and require lengthy admission. Engagement in activities could lead to improvement in negative symptoms and function, but few trials have been done. We aimed to investigate the effectiveness of a staff training intervention to increase patients' engagement in activities.

METHODS

We did a single-blind, two-arm, cluster-randomised controlled trial in 40 mental health inpatient rehabilitation units across England. Units were randomly allocated to either a manual-based staff training programme delivered by a small intervention team (intervention group, n=20) or standard care (control group, n=20). The primary outcome was patients' engagement in activities 12 months after randomisation, measured with the time use diary. With this measure, both the degree of engagement in an activity and its complexity are recorded four times a day for a week, rated on a scale of 0-4 for every period (maximum score of 112). Analysis was by intention-to-treat. Random-effects models were used to compare outcomes between study groups. Cost-effectiveness was assessed by combining service costs with the primary outcome. This study is registered with Current Controlled Trials (ISRCTN25898179).

FINDINGS

Patients' engagement in activities did not differ between study groups (coefficient 1·44, 95% CI -1·35 to 4·24). An extra £101 was needed to achieve a 1% increase in patients' engagement in activities with the study intervention.

INTERPRETATION

Our training intervention did not increase patients' engagement in activities after 12 months of follow-up. This failure could be attributable to inadequate implementation of the intervention, a high turnover of patients in the intervention units, competing priorities on staff time, high levels of patients' morbidity, and ceiling effects because of the high quality of standard care delivered. Further studies are needed to identify interventions that can improve outcomes for people with severe and complex psychosis.

FUNDING

National Institute for Health Research.

How do physicians and trainers experience outcome-based education in "Rational prescribing"?

Background

Continuing medical education (CME) is compulsory in Iran, but has shown limitations in terms of educational style and format. Outcome-based education (OBE) has been proposed internationally to create links to physicians’ actual practices. We designed an outcome-based educational intervention for general physicians in primary care (GPs). Positive outcomes on GPs’ knowledge, skills and performance in the field of rational prescribing were found and have been reported.

The specific purpose of this study was to explore the perceptions of the GPs and trainers, who participated in the outcome-based education on rational prescribing.

Methods

All nine trainers in the educational programme and 12 general physicians (out of 58) were invited to individual interviews four months after participation in the CME program. Semi-structured open-ended interviews were carried out. Qualitative content analysis was used to explore the text and to interpret meaning and intention.

Results

There was a widespread agreement that the programme improved the participants’ knowledge and skills to a higher extent than previously attended programmes. Trainers emphasized the effect of outcome-based education on their educational planning, teaching and assessment methods, while the general physicians’ challenges were how to adapt their learning in the real work environment considering social and economical barriers. Self-described attitudes and reported practice changed towards more rational prescribing.

Conclusions

Outcome-based CME seems attractive and additionally useful for general physicians in Iran and could be an effective approach when creating CME programmes to improve general physicians’ performance. Similar approaches could be considered in other contexts both regionally and globally.

Improved knowledge and reported practice regarding sexually transmitted infections among healthcare providers in rural Vietnam: a cluster randomised controlled educational intervention

BACKGROUND

Healthcare providers (HCPs) play a critical role in controlling the spread of sexually transmitted infections (STI) through early and accurate diagnosis, appropriate treatment and prevention counselling. This study aimed to assess the effectiveness of an educational intervention about STI on knowledge and reported practice among HCPs and to explore which determinants may influence the intervention's effects.

METHODS

A cluster randomized controlled educational intervention was carried out in a rural district, Vietnam. 32 communes of the district were randomized into two arms, with 160 HCPs in an STI intervention arm and 144 in a control arm. The STI intervention comprised interactive training with basic STI knowledge, case scenarios, and poster distribution. Questionnaires to evaluate knowledge and reported practice were completed three times: before, during and after the intervention. Correct answer was scored as 1; "do not know", incorrect answer was scored as 0. Univariate and multilevel multivariate analyses were applied.

RESULTS

Of the maximum 56 points, the mean knowledge score increased significantly in the STI intervention arm and in the control arm post-intervention (37.2 to 48.4, and 32.7 to 41.7, respectively). In multivariate regression analysis, knowledge improvement in the intervention arm was significantly higher than that in the control arm (regression coefficient = 2.97, p = 0.008). Other factors which positively influenced the increase in knowledge were being between 35 and 50 years old, having intermediate professional training, being a pharmacist or working at a village level (regression coefficient: 2.81, 4.43, 5.53 and 7.91, respectively). Post-intervention, the mean reported practice score increased significantly in the STI intervention arm (from 17.6 to 21.8) and insignificantly in the control arm (maximum 36 points). Factors which positively influenced the increase in reported practice were being between 35 and 50 years old, having intermediate professional training, or working at a pharmacy/drugstore (regression coefficient: 2.15, 3.33 and 3.22, respectively).

CONCLUSIONS

This study indicates that an educational intervention including interactive training and multi-faceted interventions may be effective in improving STI knowledge and reported practice of HCPs at grassroots level, particularly among pharmacists, HCPs who work in villages or pharmacies/drugstores, and who initially have low STI knowledge.

IMRT utilization in Ontario: qualitative deployment evaluation

Purpose

– The purpose of this paper is to describe a jurisdiction-wide implementation and evaluation of intensity-modulated radiation therapy (IMRT) in Ontario, Canada, highlighting innovative strategies and lessons learned.

Design/methodology/approach

– To obtain an accurate provincial representation, six cancer centres were chosen (based on their IMRT utilization, geography, population, academic affiliation and size) for an in-depth evaluation. At each cancer centre semi-structured, key informant interviews were conducted with senior administrators. An electronic survey, consisting of 40 questions, was also developed and distributed to all cancer centres in Ontario.

Findings

– In total, 21 respondents participated in the interviews and a total of 266 electronic surveys were returned. Funding allocation, guidelines and utilization targets, expert coaching and educational activities were identified as effective implementation strategies. The implementation allowed for hands-on training, an exchange of knowledge and expertise and the sharing of responsibility. Future implementation initiatives could be improved by creating stronger avenues for clear, continuing and comprehensive communication at all stages to increase awareness, garner support and encourage participation and encouraging expert-based coaching. IMRT utilization for has increased without affecting wait times or safety (from fiscal year 2008/2009 to 2012/2013 absolute increased change: prostate 46, thyroid 36, head and neck 29, sarcoma 30, and CNS 32 per cent).

Originality/value

– This multifaceted, jurisdiction-wide approach has been successful in implementing guideline recommended IMRT into standard practice. The expert based coaching initiative, in particular presents a novel training approach for those who are implementing complex techniques. This paper will be of interest to those exploring ways to fund, implement and sustain complex and evolving technologies.

DUQuE quality management measures: associations between quality management at hospital and pathway levels

Objective

The assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures.

Design

It is a multi-level, cross-sectional, mixed-method study.

Setting and Participants

As part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used.

Main Outcome Measures

Three measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR).

Results

Positive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments.

Conclusion

By using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

Results of a surgeon-directed quality improvement project on breast cancer surgery outcomes in South-Central Ontario

BACKGROUND

Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.

METHODS

Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.

RESULTS

Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.

CONCLUSIONS

This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.