Changing physician behavior: half‐empty or half‐full?

Developing and applying synergistic multilevel implementation strategies to promote reach of an evidence-based parenting intervention in primary care

Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed.

Plain Language Summary

There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.

Training on involving cognitions and perceptions in the occupational health management and work disability assessment of workers: development and evaluation

BACKGROUND

In order to improve work participation of workers with a chronic disease, it is important for occupational health professionals (OHPs) to focus on those factors that can influence work participation. Cognitions and perceptions, such as recovery expectations and self-efficacy, are examples of these factors that can influence work participation. However, no training program is available for OHPs on how to involve cognitions and perceptions during their practice. Therefore, the aim of this study was to develop a training program for OHPs on how to involve cognitions and perceptions in the occupational health management and work disability assessment of workers with a chronic disease. In addition, to evaluate the OHPs' satisfaction with the training and the feasibility of the training and learned skills.

METHODS

The training program was developed using information from previously conducted studies regarding cognitions and perceptions in relation to work participation. Satisfaction with the training by OHPs was evaluated by means of a questionnaire. A smaller group of OHPs were interviewed three to six months after the training to evaluate the feasibility of the training and learned skills.

RESULTS

The 4.5-h training program consisted of four parts concerning: 1) cognitions and perceptions associated with work participation, 2) how to obtain information on them, 3) the course of the conversation on these factors, and 4) intervening on these factors. Eight training sessions were conducted with 57 OHPs, of whom 54 evaluated the training. Participants were very satisfied (score 8.5 on a scale from 1 to 10). The eleven interviewed participants were more aware of cognitions and perceptions during consultations and perceived the training to be feasible. However, not all participants had applied the acquired skills in their practice, partially because of a lack of time.

CONCLUSIONS

OHPs are very satisfied with the training program and perceive it to be feasible. The training increases awareness of important cognitions and perceptions and may possibly help to increase work participation of workers with a chronic disease.

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Background

An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice.

Objectives

To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.

Design

A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group.

Review methods

Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations.

Results

A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection.

Limitations

Limitations were the low quality of included literature and limited number of UK-based studies.

Future work

Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS.

Study registration

This study is registered as PROSPERO CRD42018088779.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Can a multicomponent multidisciplinary implementation package change physicians' and nurses' perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial

BACKGROUND

The Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals.

METHODS

A survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time.

RESULT

The response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses' responses.

CONCLUSION

TIPS resulted in changes in some aspects of nurses' perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample.

TRIAL REGISTRATION

ACTRN12613000939796, UTN: U1111-1145-6762.

The changing landscape of professional practice in podiatry, lessons to be learned from other professions about the barriers to change - a narrative review

BACKGROUND

The delivery of healthcare is changing and aligned with this, the podiatry profession continues to change with evidence informed practice and extending roles. As change is now a constant, this gives clinicians the opportunity to take ownership to drive that change forward. In some cases, practitioners and their teams have done so, where others have been reluctant to embrace change. It is not clear to what extent good practice is being shared, whether interventions to bring about change have been successful, or what barriers exist that have prevented change from occurring. The aim of this article is to explore the barriers to changing professional practice and what lessons podiatry can learn from other health care professions.

MAIN BODY

A literature search was carried out which informed a narrative review of the findings. Eligible papers had to (1) examine the barriers to change strategies, (2) explore knowledge, attitudes and roles during change interventions, (3) explore how the patients/service users contribute to the change process (4) include studies from predominantly primary care in developed countries.Ninety-two papers were included in the final review. Four papers included change interventions involving podiatrists. The barriers influencing change were synthesised into three themes (1) the organisational context, (2) the awareness, knowledge and attitudes of the professional, (3) the patient as a service user and consumer.

CONCLUSIONS

Minimal evidence exists about the barriers to changing professional practice in podiatry. However, there is substantial literature on barriers and implementation strategies aimed at changing professional practices in other health professions. Change in practice is often resisted at an organisational, professional or service user level. The limited literature about change in podiatry, a rapidly changing healthcare workforce and the wide range of contexts that podiatrists work, highlights the need to improve the ways in which podiatrists can share successful attempts to change practice.

Incentives and disincentives for the treatment of depression and anxiety: a scoping review

OBJECTIVE

There is widespread support for primary care to help address growing mental health care demands. Incentives and disincentives are widely used in the design of health care systems to help steer toward desired goals. The absence of a conceptual model to help understand the range of factors that influence the provision of primary mental health care inspired a scoping review of the literature. Understanding the incentives that promote and the disincentives that deter treatment for depression and anxiety in the primary care context will help to achieve goals of greater access to mental health care.

METHOD

A review of the literature was conducted to answer the question, how are incentives and disincentives conceptualized in studies investigating the treatment of common mental disorders in primary care? A comprehensive search of MEDLINE, PsycINFO, CINAHL, and Google Scholar was undertaken using Arksey and O'Malley's 5-stage methodological framework for scoping reviews.

RESULTS

We identified 27 studies. A range of incentives and disincentives influence the success of primary mental health care initiatives to treat depression and anxiety. Six types of incentives and disincentives can encourage or discourage treatment of depression and anxiety in primary care: attitudes and beliefs, training and core competencies, leadership, organizational, financial, and systemic.

CONCLUSIONS

Understanding that there are 6 different types of incentives that influence treatment for anxiety and depression in primary care may help service planners who are trying to promote improved mental health care.

A guideline-based approach to asthma management

The management of asthma has dramatically improved in recent years because of a better understanding of the disease and an organized approach to therapy. All of the various components and tools for evaluating individuals with asthma may be found in the Expert Panel Report Guidelines by the National Heart, Lung, and Blood Institute, initially published in 2007. These comprehensive guidelines help health care professionals care for individuals with asthma throughout their lifespan. This article will assist the health care provider to use these evidence-based guidelines.

Implementation and evaluation of a multisite drug usage evaluation program across Australian hospitals - a quality improvement initiative

BACKGROUND

With the use of medicines being a broad and extensive part of health management, mechanisms to ensure quality use of medicines are essential. Drug usage evaluation (DUE) is an evidence-based quality improvement methodology, designed to improve the quality, safety and cost-effectiveness of drug use. The purpose of this paper is to describe a national DUE methodology used to improve health care delivery across the continuum through multi-faceted intervention involving audit and feedback, academic detailing and system change, and a qualitative assessment of the methodology, as illustrated by the Acute Postoperative Pain Management (APOP) project.

METHODS

An established methodology, consisting of a baseline audit of inpatient medical records, structured patient interviews and general practitioner surveys, followed by an educational intervention and follow-up audit, is used. Australian hospitals, including private, public, metropolitan and regional, are invited to participate on a voluntary basis. De-identified data collected by hospitals are collated and evaluated nationally to provide descriptive comparative analyses. Hospitals benchmark their practices against state and national results to facilitate change. The educational intervention consists of academic detailing, group education, audit and feedback, point-of-prescribing prompts and system changes. A repeat data collection is undertaken to assess changes in practice.An online qualitative survey was undertaken to evaluate the APOP program. Qualitative assessment of hospitals' perceptions of the effectiveness of the overall DUE methodology and changes in procedure/prescribing/policy/clinical practice which resulted from participation were elicited.

RESULTS

62 hospitals participated in the APOP project. Among 23 respondents to the evaluation survey, 18 (78%) reported improvements in the documentation of pain scores at their hospital. 15 (65%) strongly agreed or agreed that participation in APOP directly resulted in increased prescribing of multimodal analgesia for pain relief in postoperative patients.

CONCLUSIONS

This national DUE program has facilitated the engagement and participation of a number of acute health care facilities to address issues relating to quality use of medicine. This approach has been perceived to be effective in helping them achieve improvements in patient care.

An intervention to change clinician behavior: Conceptual framework for the multicolored simplified asthma guideline reminder (MSAGR)

Clinical practice guidelines decrease variation in health care because they standardize the care offered by healthcare providers. Seventeen years after publication, the National Asthma Education and Prevention Program (NAEPP) guidelines are considered the "gold standard" in asthma care, yet they remain underutilized despite three revisions with the latest in July 2007. Multiple factors are presented for lack of adherence to the guidelines. This article discusses the Multicolored, Simplified Asthma Guideline Reminder (MSAGR), an algorithm chart intervention for helping change clinicians' behavior for better adherence to the NAEPP guidelines, and describes the conceptual framework underpinning this intervention as a means of predicting better outcomes for providers and children.

Motivational determinants among physicians in Lahore, Pakistan

Introduction

Human resource crises in developing countries have been identified as a critical aspect of poor quality and low accessibility in health care. Worker motivation is an important facet of this issue. Specifically, motivation among physicians, who are an important bridge between health systems and patients, should be considered. This study aimed to identify the determinants of job motivation among physicians, a neglected perspective, especially in developing countries.

Methods

A stratified random sample of 360 physicians was selected from public primary, public secondary and public and private tertiary health facilities in the Lahore district, Pakistan. Pretested, semi-structured, self-administered questionnaires were used. For the descriptive part of this study, physicians were asked to report their 5 most important work motivators and demotivators within the context of their current jobs and in general. Responses were coded according to emergent themes and frequencies calculated. Of the 30 factors identified, 10 were classified as intrinsic, 16 as organizational and 4 as socio-cultural.

Results

Intrinsic and socio-cultural factors like serving people, respect and career growth were important motivators. Conversely, demotivators across setups were mostly organizational, especially in current jobs. Among these, less pay was reported the most frequently. Fewer opportunities for higher qualifications was a demotivator among primary and secondary physicians. Less personal safety and poor working conditions were important in the public sector, particularly among female physicians. Among private tertiary physicians financial incentives other than pay and good working conditions were motivators in current jobs. Socio-cultural and intrinsic factors like less personal and social time and the inability to financially support oneself and family were more important among male physicians.

Conclusion

Motivational determinants differed across different levels of care, sectors and genders. Nonetheless, the important motivators across setups in this study were mostly intrinsic and socio-cultural, which are difficult to affect while the demotivators were largely organizational. Many can be addressed even at the facility level such as less personal safety and poor working conditions. Thus, in resource limited settings a good strategic starting point could be small scale changes that may markedly improve physicians' motivation and subsequently the quality of health care.

Realignment of incentives for health-care providers in China

Inappropriate incentives as part of China's fee-for-service payment system have resulted in rapid cost increase, inefficiencies, poor quality, unaffordable health care, and an erosion of medical ethics. To reverse these outcomes, a strategy of experimentation to realign incentives for providers with the social goals of improvement in quality and efficiency has been initiated in China. This Review shows how lessons that have been learned from international experiences have been improved further in China by realignment of the incentives for providers towards prevention and primary care, and incorporation of a treatment protocol for hospital services. Although many experiments are new, preliminary evidence suggests a potential to produce savings in costs. However, because these experiments have not been scientifically assessed in China, evidence of their effects on quality and health outcome is largely missing. Although a reform of the provider's payment can be an effective short-term strategy, professional ethics need to be re-established and incentives changed to alter the profit motives of Chinese hospitals and physicians alike. When hospitals are given incentives to achieve maximum profit, incentives for hospitals and physicians must be separated.

Preparing Physicians for the 21 Century: Targeting Communication Skills and the Promotion of Health Behavior Change

The prevalence of behavior-related diseases is a predominant concern in the health care profession. Further complicating matters, the biomedical disease model has demonstrated limited effectiveness in treating the consequential array of chronic health conditions. Medical educators have been tasked with developing curricula to better prepare physicians to address the complex health issues of the 21(st) century. A review of empirically supported educational endeavors is essential in planning for future interventions. Prior efforts specific to physician-patient communication and the promotion of health behavior change will be reviewed. Opportunities to enhance medical education by targeting patient-centered care, attitudinal measures, individualized training, and an empirically supported, theoretically based model of change will be presented.

Assessment and remediation for physicians with suspected performance problems: an international survey

INTRODUCTION

Little is known about the overall appropriateness and value of the various programs available internationally for assessment and remediation for individual physicians whose performance in their clinical practice has been identified as giving cause for concern.

METHOD

A questionnaire was e-mailed to members of the International Physicians Assessment Coalition and/or the Coalition for Physician Enhancement--organizations that were thought to provide this type of assessment (n = 20). Questions covered the aims, organization, methods, and outcomes of assessment programs and associated remediation.

RESULTS

Responses came from 15 regulatory bodies, universities, not-for-profits, and health service organizations in 5 countries. The assessment programs and remediation activities identified were small in scale. Their focus ranged from a narrow concern with identifying and repairing specific knowledge and skills deficits to a wider interest in the biopsychosocial functioning of the physician as a whole. Both "diagnosis" and "treatment" of problems focused on the individual physician. Less attention was given to broader systems or contextual factors that might impact performance. Although progress through remediation was carefully monitored, none of the programs undertook regular systematic follow-up to ascertain the success of their interventions in the longer term.

DISCUSSION

This field of activity is characterized by the use of sophisticated methods for measuring performance/competence, but provision of remediation is more patchy and variable. The small scale of these programs raises questions about the relationship between scale of provision and potential need for remediation. Gaps in information about impact and outcomes mean that the overall impact and value of this type of assessment and remediation is hard to determine.

The polity of academic medicine: a critical analysis of autocratic governance

How should academic radiology departments be governed? This question has rarely been directly addressed in the radiology literature. The dominant model of administration in present-day academic departments differs from that typically seen in private group practices. Whereas private group practices tend to follow a democratic model whereby key decisions must be supported by a majority of the partners, in academic institutions, medical school deans and department chairs generally possess great latitude in strategic and operational decision making. This article considers arguments for and against "top-down" governance in academia. The rationale supporting this form of governance is weak, and the best evidence from the fields of management and organizational behavior suggests it may in fact be detrimental.