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Lynch EA, Bulto LN, Cheng H, Craig L, Luker JA, Bagot KL, Thayabaranathan T, Janssen H, McInnes E, Middleton S, Cadilhac DA. Interventions for the uptake of evidence-based recommendations in acute stroke settings. Cochrane Database Syst Rev 2023; 8:CD012520. [PMID: 37565934 PMCID: PMC10416310 DOI: 10.1002/14651858.cd012520.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care. OBJECTIVES To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date. SELECTION CRITERIA We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations. MAIN RESULTS We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes. AUTHORS' CONCLUSIONS We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.
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Affiliation(s)
| | - Lemma N Bulto
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Heilok Cheng
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Julie A Luker
- Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Kathleen L Bagot
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
| | | | - Heidi Janssen
- School of Health Sciences, The University of Newcastle, Callaghan, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
- NSW School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Dominique A Cadilhac
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, Australia
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Soltani I, Beaulieu MC, Sestier M, Shen HC, Hillani A, Matteau A, Mansour S, Potter BJ. Adherence to Cardiovascular Prevention Guidelines in an Academic Centre. CJC Open 2023; 5:530-536. [PMID: 37496787 PMCID: PMC10366625 DOI: 10.1016/j.cjco.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/20/2023] [Indexed: 07/28/2023] Open
Abstract
Background Adherence to guidelines is associated with better patient outcomes. Although studies show suboptimal adherence to cardiovascular prevention guidelines among general practitioners, adherence among specialist physicians is understudied. The aim of this analysis was to identify practice gaps among cardiologists in a tertiary academic centre. Methods We retrospectively audited cardiology outpatient clinic notes taken at the Cardiology Clinic at the Centre hospitalier de l'Université de Montréal (CHUM), from the period January 1, 2019 to February 28, 2019. Data were abstracted from hospital medical records. The primary outcome of interest was the rate of adherence to cardiovascular prevention guidelines. We compared the chart-documented practice at our centre to the Canadian hypertension, lipid, diabetes, antiplatelet, and heart failure guidelines in effect at the time of the audit. We also collected information regarding discussions of smoking, alcohol consumption, physical activity, and diet. Results A total of 2503 patients were included, with a mean age of 65.6 ± 14.5 years. Dyslipidemia occurred in 63% of patients, hypertension in 55%, and coronary artery disease in 41%. Optimal low-density lipoprotein control was documented as having been achieved in just 39% of cases. Blood pressure control was adequate for 65% of patients, and glycemic control was achieved in 47% of patients with diabetes. Heart failure treatment was optimal in 34% of patients. Nearly all patients with coronary artery disease (95%) had appropriate antithrombotic therapy. The incidence of discussion of nonpharmacologic interventions varied, ranging from 91% (smoking) to 16% (diet). Conclusions Primary and secondary prevention of cardiovascular events was found to be suboptimal in an academic tertiary-care outpatient cardiology clinic and may be representative of similar shortcomings nationwide. Strategies to ensure guideline adherence are needed.
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Affiliation(s)
- Iness Soltani
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Marie-Claude Beaulieu
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Maude Sestier
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Hao Cheng Shen
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Ali Hillani
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Alexis Matteau
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Samer Mansour
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
| | - Brian J. Potter
- Centre hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Centre, Montreal, Québec, Canada
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Machline-Carrion MJ, Soares RM, Damiani LP, Campos VB, Sampaio B, Fonseca FH, Izar MC, Amodeo C, Pontes-Neto OM, Santos JY, Gomes SPDC, Saraiva JFK, Ramacciotti E, Barros E Silva PGDM, Lopes RD, Brandão da Silva N, Guimarães HP, Piegas L, Stein AT, Berwanger O. Effect of a Multifaceted Quality Improvement Intervention on the Prescription of Evidence-Based Treatment in Patients at High Cardiovascular Risk in Brazil: The BRIDGE Cardiovascular Prevention Cluster Randomized Clinical Trial. JAMA Cardiol 2020; 4:408-417. [PMID: 30942842 DOI: 10.1001/jamacardio.2019.0649] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Studies have found that patients at high cardiovascular risk often fail to receive evidence-based therapies in community practice. Objective To evaluate whether a multifaceted quality improvement intervention can improve the prescription of evidence-based therapies. Design, Setting, and Participants In this 2-arm cluster randomized clinical trial, patients with established atherothrombotic disease from 40 public and private outpatient clinics (clusters) in Brazil were studied. Patients were recruited from August 2016 to August 2017, with follow-up to August 2018. Data were analyzed in September 2018. Interventions Case management, audit and feedback reports, and distribution of educational materials (to health care professionals and patients) vs routine practice. Main Outcomes and Measures The primary end point was prescription of evidence-based therapies (ie, statins, antiplatelet therapy, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) using the all-or-none approach at 12 months after the intervention period in patients without contraindications. Results Of the 1619 included patients, 1029 (63.6%) were male, 1327 (82.0%) had coronary artery disease (843 [52.1%] with prior acute myocardial infarction), 355 (21.9%) had prior ischemic stroke or transient ischemic attack, and 197 (12.2%) had peripheral vascular disease, and the mean (SD) age was 65.6 (10.5) years. Among randomized clusters, 30 (75%) were cardiology sites, 6 (15%) were primary care units, and 26 (65%) were teaching institutions. Among eligible patients, those in intervention clusters were more likely to receive a prescription of evidence-based therapies than those in control clusters (73.5% [515 of 701] vs 58.7% [493 of 840]; odds ratio, 2.30; 95% CI, 1.14-4.65). There were no differences between the intervention and control groups with regards to risk factor control (ie, hyperlipidemia, hypertension, or diabetes). Rates of education for smoking cessation were higher among current smokers in the intervention group than in the control group (51.9% [364 of 701] vs 18.2% [153 of 840]; odds ratio, 11.24; 95% CI, 2.20-57.43). The rate of cardiovascular mortality, acute myocardial infarction, and stroke was 2.6% for patients from intervention clusters and 3.4% for those in the control group (hazard ratio, 0.76; 95% CI, 0.43-1.34). Conclusions and Relevance Among Brazilian patients at high cardiovascular risk, a quality improvement intervention resulted in improved prescription of evidence-based therapies. Trial Registration ClinicalTrials.gov identifier: NCT02851732.
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Affiliation(s)
| | | | | | | | - Bruna Sampaio
- HCor Research Institute, Hospital do Coração, São Paulo, São Paulo, Brazil
| | | | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, São Paulo, Brazil.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nilton Brandão da Silva
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Airton T Stein
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Otávio Berwanger
- HCor Research Institute, Hospital do Coração, São Paulo, São Paulo, Brazil
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