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Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, Boyd KA, Craig N, French DP, McIntosh E, Petticrew M, Rycroft-Malone J, White M, Moore L. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. Int J Nurs Stud 2024; 154:104705. [PMID: 38564982 DOI: 10.1016/j.ijnurstu.2024.104705] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The UK Medical Research Council's widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.
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Affiliation(s)
- Kathryn Skivington
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Lynsay Matthews
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sharon Anne Simpson
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Jane M Blazeby
- Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Bristol Biomedical Research Centre, Bristol, UK
| | - Kathleen Anne Boyd
- Health Economics and Health Technology Assessment Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - David P French
- Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mark Petticrew
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Martin White
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Laurence Moore
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Bogerd MJ, Exmann CJ, Slottje P, Bont J, Van Hout HP. Predicting anticipated benefit from an extended consultation to personalise care in multimorbidity: a development and internal validation study of a prioritisation algorithm in general practice. Br J Gen Pract 2024; 74:e307-e314. [PMID: 38164549 PMCID: PMC11044021 DOI: 10.3399/bjgp.2023.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/04/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Persons with multimorbidity may gain from person-centred care compared with the current protocolised chronic-disease management in Dutch general practice. Given time constraints and limited resources, it is essential to prioritise those most in need of an assessment of person-centred chronic-care needs. AIM To develop and validate a prioritisation algorithm based on routine electronic medical record (EMR) data that distinguishes between patients with multimorbidity who would, and those who would not, benefit from an extended person-centred consultation to assess person-centred chronic-care needs, as judged by GPs. DESIGN AND SETTING A mixed-methods study was conducted in five general practices in the north-west region of the Netherlands. Four out of the five practices were situated in rural areas. METHOD Multivariable logistic regression using EMR data to predict the GPs' judgement on patients' anticipated benefit from an extended consultation, as well as a thematic analysis of a focus group exploring GPs' clinical reasoning for this judgement were conducted. Internal validation was performed using 10-fold cross-validation. Multimorbidity was defined as the presence of ≥3 chronic conditions. RESULTS In total, EMRs from 1032 patients were included in the analysis; of these, 352 (34.1%) were judged to have anticipated benefit. The model's cross-validated C-statistic was 0.72 (95% confidence interval = 0.70 to 0.75). Calibration was good. Presence of home visit(s) and history of myocardial infarction were associated with anticipated benefit. Thematic analysis revealed three dimensions feeding anticipated benefit: GPs' cause for concern, patients' mindset regarding their conditions, and balance between received care/expected care needed. CONCLUSION This algorithm may facilitate automated prioritisation, potentially avoiding the need for GPs to personally triage the whole practice population that has multimorbidity. However, external validation of the algorithm and evaluation of actual benefit of consultation is recommended before implementation.
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Affiliation(s)
- Mieke Jl Bogerd
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Collin Jc Exmann
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Pauline Slottje
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jettie Bont
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Hein Pj Van Hout
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Brünn R, Basten J, Lemke D, Piotrowski A, Söling S, Surmann B, Greiner W, Grandt D, Kellermann-Mühlhoff P, Harder S, Glasziou P, Perera R, Köberlein-Neu J, Ihle P, van den Akker M, Timmesfeld N, Muth C. Digital Medication Management in Polypharmacy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:243-250. [PMID: 38377330 PMCID: PMC11381212 DOI: 10.3238/arztebl.m2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Inappropriate drug prescriptions for patients with polypharmacy can have avoidable adverse consequences. We studied the effects of a clinical decision-support system (CDSS) for medication management on hospitalizations and mortality. METHODS This stepped-wedge, cluster-randomized, controlled trial involved an open cohort of adult patients with polypharmacy in primary care practices (=clusters) in Westphalia-Lippe, Germany. During the period of the intervention, their medication lists were checked annually using the CDSS. The CDSS warns against inappropriate prescriptions on the basis of patient-related health insurance data. The combined primary endpoint consisted of overall mortality and hospitalization for any reason. The secondary endpoints were mortality, hospitalizations, and high-risk prescription. We analyzed the quarterly health insurance data of the intention- to-treat population with a mixed logistic model taking account of clustering and repeated measurements. Sensitivity analyses addressed effects of the COVID-19 pandemic and other effects. RESULTS 688 primary care practices were randomized, and data were obtained on 42 700 patients over 391 994 quarter years. No significant reduction was found in either the primary endpoint (odds ratio [OR] 1.00; 95% confidence interval [0.95; 1.04]; p = 0.8716) or the secondary endpoints (hospitalizations: OR 1.00 [0.95; 1.05]; mortality: OR 1.04 [0.92; 1.17]; high-risk prescription: OR 0.98 [0.92; 1.04]). CONCLUSION The planned analyses did not reveal any significant effect of the intervention. Pandemicadjusted analyses yielded evidence that the mortality of adult patients with polypharmacy might potentially be lowered by the CDSS. Controlled trials with appropriate follow-up are needed to prove that a CDSS has significant effects on mortality in patients with polypharmacy.
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Affiliation(s)
- Robin Brünn
- Institute of General Practice, Goethe University Frankfurt am Main; Pharmacy of University Hospital Frankfurt; Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum; Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum; Institute of General Practice, Goethe University Frankfurt am Main; Working Group General and Family Medicine, Medical Faculty East Westphalia-Lippe, University of Bielefeld; Institute of General Practice, Goethe University Frankfurt am Main; Bergisch Competence Center for Health Economics and Health Services Research, Bergische University Wuppertal; Chair of General Medicine II and Patient Orientation in Primary Care, Institute of General Medicine and Ambulatory Health Care (iamag), University Witten/Herdecke; Working Group for Health Economics and Health Management, Faculty of ; Health Sciences, Bielefeld University; Chairman of the Drug Therapy Management and Drug Therapy Safety Commission, German Society for Internal Medicine (DGIM); Barmer, Wuppertal; Institute of Clinical Pharmacology, University Hospital and Faculty of Medicine, Goethe University Frankfurt, Frankfurt am Main; Institute for Evidence-Based Healthcare, Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, 4229, Australia; Nuffield Department of Primary Care Health Sciences, University of Oxford, UK; PMV Research Group, Faculty of Medicine, University Hospital Cologne, University of Cologne; Institute of General Practice, Goethe-University Frankfurt am Main; Department of Family Medicine, Care and Public Health Research Institute, Maastricht University; Department of Public Health and Primary Care, Academic Centre of General Practice, KU Leuven
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Dopp AR, Hindmarch G, Osilla KC, Meredith LS, Manuel JK, Becker K, Tarhuni L, Schoenbaum M, Komaromy M, Cassells A, Watkins KE. Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers. EVIDENCE & POLICY : A JOURNAL OF RESEARCH, DEBATE AND PRACTICE 2024; 20:15-35. [PMID: 38911233 PMCID: PMC11192460 DOI: 10.1332/17442648y2023d000000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Background Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange. Aims and objectives We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs). Methods We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors. Findings Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic. Discussion and conclusion Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.
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Nicolau V, Brandão D, Rua T, Escoval A. Organisation and integrated healthcare approaches for people living with HIV, multimorbidity, or both: a systematic review. BMC Public Health 2023; 23:1579. [PMID: 37596539 PMCID: PMC10439547 DOI: 10.1186/s12889-023-16485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 08/09/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Universal recommendation for antiretroviral drugs and their effectiveness has put forward the challenge of assuring a chronic and continued care approach to PLHIV (People Living with HIV), pressured by aging and multimorbidity. Integrated approaches are emerging which are more responsive to that reality. Studying those approaches, and their relation to the what of delivery arrangements and the how of implementation processes, may support future strategies to attain more effective organizational responses. METHODS We reviewed empirical studies on either HIV, multimorbidity, or both. The studies were published between 2011 and 2020, describing integrated approaches, their design, implementation, and evaluation strategy. Quantitative, qualitative, or mixed methods were included. Electronic databases reviewed cover PubMed, SCOPUS, and Web of Science. A narrative analysis was conducted on each study, and data extraction was accomplished according to the Effective Practice and Organisation of Care taxonomy of health systems interventions. RESULTS A total of 30 studies, reporting 22 different interventions, were analysed. In general, interventions were grounded and guided by models and frameworks, and focused on specific subpopulations, or priority groups at increased risk of poorer outcomes. Interventions mixed multiple integrated components. Delivery arrangements targeted more frequently clinical integration (n = 13), and care in proximity, community or online-telephone based (n = 15). Interventions reported investments in the role of users, through self-management support (n = 16), and in coordination, through multidisciplinary teams (n = 9) and continuity of care (n = 8). Implementation strategies targeted educational and training activities (n = 12), and less often, mechanisms of iterative improvement (n = 3). At the level of organizational design and governance, interventions mobilised users and communities through representation, at boards and committees, and through consultancy, along different phases of the design process (n = 11). CONCLUSION The data advance important lessons and considerations to take steps forward from disease-focused care to integrated care at two critical levels: design and implementation. Multidisciplinary work, continuity of care, and meaningful engagement of users seem crucial to attain care that is comprehensive and more proximal, within or cross organizations, or sectors. Promising practices are advanced at the level of design, implementation, and evaluation, that set integration as a continued process of improvement and value professionals and users' knowledge as assets along those phases. TRIAL REGISTRATION PROSPERO number CRD42020194117.
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Affiliation(s)
- Vanessa Nicolau
- NOVA National School of Public Health, Public Health Research Center, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal.
| | - Daniela Brandão
- NOVA National School of Public Health, Public Health Research Center, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | | | - Ana Escoval
- NOVA National School of Public Health, Public Health Research Center, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
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French C, Dowrick A, Fudge N, Pinnock H, Taylor SJC. What do we want to get out of this? a critical interpretive synthesis of the value of process evaluations, with a practical planning framework. BMC Med Res Methodol 2022; 22:302. [PMID: 36434520 PMCID: PMC9700891 DOI: 10.1186/s12874-022-01767-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/21/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Process evaluations aim to understand how complex interventions bring about outcomes by examining intervention mechanisms, implementation, and context. While much attention has been paid to the methodology of process evaluations in health research, the value of process evaluations has received less critical attention. We aimed to unpack how value is conceptualised in process evaluations by identifying and critically analysing 1) how process evaluations may create value and 2) what kind of value they may create. METHODS We systematically searched for and identified published literature on process evaluation, including guidance, opinion pieces, primary research, reviews, and discussion of methodological and practical issues. We conducted a critical interpretive synthesis and developed a practical planning framework. RESULTS We identified and included 147 literature items. From these we determined three ways in which process evaluations may create value or negative consequences: 1) through the socio-technical processes of 'doing' the process evaluation, 2) through the features/qualities of process evaluation knowledge, and 3) through using process evaluation knowledge. We identified 15 value themes. We also found that value varies according to the characteristics of individual process evaluations, and is subjective and context dependent. CONCLUSION The concept of value in process evaluations is complex and multi-faceted. Stakeholders in different contexts may have very different expectations of process evaluations and the value that can and should be obtained from them. We propose a planning framework to support an open and transparent process to plan and create value from process evaluations and negotiate trade-offs. This will support the development of joint solutions and, ultimately, generate more value from process evaluations to all.
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Affiliation(s)
- Caroline French
- grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB UK
| | - Anna Dowrick
- grid.4991.50000 0004 1936 8948Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GC UK
| | - Nina Fudge
- grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB UK
| | - Hilary Pinnock
- grid.4305.20000 0004 1936 7988Usher Institute, The University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Stephanie J. C. Taylor
- grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB UK
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McCarthy C, Pericin I, Smith SM, Kiely B, Moriarty F, Wallace E, Clyne B. Patient and general practitioner experiences of implementing a medication review intervention in older people with multimorbidity: Process evaluation of the SPPiRE trial. Health Expect 2022; 25:3225-3237. [PMID: 36245339 DOI: 10.1111/hex.13630] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The SPPiRE cluster randomized controlled trial found that a general practitioner (GP)-delivered medication review that incorporated screening for potentially inappropriate prescriptions (PIP), a brown bag review and a patient priority assessment, resulted in a significant but small reduction in the number of medicines and no significant reduction in PIP. This process evaluation aims to explore the experiences of GPs and patients and the potential for system-wide implementation. METHODS The trial included 51 general practices and 404 participants with multimorbidity aged ≥65 years, prescribed ≥15 medicines. The process evaluation used mixed methods and ran parallel to the trial. Quantitative data was collected from the SPPiRE intervention website and analysed descriptively. Qualitative data on medication changes were collected from intervention GPs (18/26) and a purposive sample of intervention patients (27/208) via semi-structured telephone interviews. All interviews were transcribed verbatim and analysed using a thematic analysis. Qualitative and quantitative data were integrated using a triangulation protocol. RESULTS The analysis generated two themes, intervention implementation and mechanisms of action, and both were underpinned by the theme of context. Intervention delivery varied among practices and 45 patients (28%) had no review, primarily due to insufficient GP time. 80% of reviewed patients had ≥1 PIP identified, 59% had ≥1 problem identified during the brown bag review and 79% had ≥1 priority recorded. The brown bag review resulted in the most deprescription of medications. GPs and patients responded positively to the intervention but most GPs did not engage with the patient priority-setting process. GPs identified a lack of integration into practice software and resources as barriers to future implementation. CONCLUSION The SPPiRE intervention had a small effect in reducing the number of medicines and this was primarily mediated through the brown bag review. The context of resource shortages and deep-seated views around medical decision-making influenced intervention implementation. PATIENT OR PUBLIC CONTRIBUTION Qualitative data on the implementation of the medication review and their wider views on their medicines was collected from older people with multimorbidity through semi-structured telephone interviews. CLINICAL TRIAL REGISTRATION The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).
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Affiliation(s)
- Caroline McCarthy
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ivana Pericin
- School of Social Work and Social Policy, Trinity College Dublin, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland.,Department of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
| | - Bridget Kiely
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Barbara Clyne
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Juskevicius LF, Luz RA, Felix AMDS, Timmons S, Padoveze MC. Lessons learned from a failed implementation: Effective communication with patients in transmission-based precautions. Am J Infect Control 2022; 51:687-693. [PMID: 36209943 DOI: 10.1016/j.ajic.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/27/2022] [Accepted: 09/27/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patient engagement with transmission-based precautions can be an important strategy to prevent adverse events related to isolation. Most patient education is still highly prescriptive and is thus unlikely to help. Effective communication requires behavior change, leading to a meaningful dialog between the parties involved. OBJECTIVE evaluate implementation process of a protocol for effective communication with patients in transmission-based precautions (Com-Efe). METHODS Implementation research using qualitative methods in 4 sequential phases: (1) nonparticipant observation in inpatient wards; (2) design of the intervention for implementation; (3) adaptation of the Com-Efe through workshops with nurses; (4) final assessment of the implementation results through interviews with nurses. Study was performed in a public, secondary, teaching hospital. Consolidated Framework for Implementation Research was used as the reference for interview design and data analysis, aiming to identify barriers and enablers of the implementation process. RESULTS Main factors that could have facilitated adherence were beliefs and perceived advantages in using the Com-Efe by nurses. Main barriers that may have contributed to the failure were the unfavorable climate for implementation, insufficient individual and leadership commitment, and the lack of understanding of the concepts underpinning effective communication. CONCLUSIONS Despite using a systematic approach, the Com-Efe protocol was not fully implemented. The lessons learned in this study allowed us to propose suggestions for future protocol implementations in similar contexts.
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Affiliation(s)
| | - Reginaldo A Luz
- Departament of Nursing, Santa Casa de São Paulo School of Medical Sciences, São Paulo, São Paulo, Brazil
| | - Adriana M da Silva Felix
- Departament of Nursing, Santa Casa de São Paulo School of Medical Sciences, São Paulo, São Paulo, Brazil
| | - Stephen Timmons
- Nottingham University Business School, University of Nottingham, Nottingham, Nottinghamshire, United Kingdom
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Skou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, Boyd CM, Pati S, Mtenga S, Smith SM. Multimorbidity. Nat Rev Dis Primers 2022; 8:48. [PMID: 35835758 PMCID: PMC7613517 DOI: 10.1038/s41572-022-00376-4] [Citation(s) in RCA: 262] [Impact Index Per Article: 131.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.
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Affiliation(s)
- Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.
| | - Frances S Mair
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Bruno P Nunes
- Postgraduate Program in Nursing, Faculty of Nursing, Universidade Federal de Pelotas, Pelotas, Brazil
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Epidemiology and Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Sanghamitra Pati
- ICMR Regional Medical Research Centre, Bhubaneswar, Odisha, India
| | - Sally Mtenga
- Department of Health System Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Susan M Smith
- Discipline of Public Health and Primary Care, Institute of Population Health, Trinity College Dublin, Russell Building, Tallaght Cross, Dublin, Ireland
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Brünn R, Lemke D, Basten J, Kellermann-Mühlhoff P, Köberlein-Neu J, Muth C, van den Akker M. Use of an Electronic Medication Management Support System in Patients with Polypharmacy in General Practice: A Quantitative Process Evaluation of the AdAM Trial. Pharmaceuticals (Basel) 2022; 15:ph15060759. [PMID: 35745678 PMCID: PMC9230750 DOI: 10.3390/ph15060759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/21/2022] Open
Abstract
Polypharmacy is associated with a risk of negative health outcomes. Potentially inappropriate medications, interactions resulting from contradicting medical guidelines, and inappropriate monitoring, all increase the risk. This process evaluation (PE) of the AdAM study investigates implementation and use of a computerized decision-support system (CDSS). The CDSS analyzes medication appropriateness by including claims data, and hence provides general practitioners (GPs) with full access to patients’ medical treatments. We based our PE on pseudonymized logbook entries into the CDSS and used the four dimensions of the Medical Research Council PE framework. Reach, which examines the extent to which the intended study population was included, and Dose, Fidelity, and Tailoring, which examine how the software was actually used by GPs. The PE was explorative and descriptive. Study participants were representative of the target population, except for patients receiving a high level of nursing care, as they were treated less frequently. GPs identified and corrected inappropriate prescriptions flagged by the CDSS. The frequency and intensity of interventions documented in the form of logbook entries lagged behind expectations, raising questions about implementation barriers to the intervention and the limitations of the PE. Impossibility to connect the CDSS to GPs’ electronic medical records (EMR) of GPs due to technical conditions in the German healthcare system may have hindered the implementation of the intervention. Data logged in the CDSS may underestimate medication changes in patients, as documentation was voluntary and already included in EMR.
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Affiliation(s)
- Robin Brünn
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (D.L.); (C.M.); (M.v.d.A.)
- Correspondence:
| | - Dorothea Lemke
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (D.L.); (C.M.); (M.v.d.A.)
| | - Jale Basten
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44789 Bochum, Germany;
| | | | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, 42119 Wuppertal, Germany;
| | - Christiane Muth
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (D.L.); (C.M.); (M.v.d.A.)
- Department of General Practice and Family Medicine, Medical Faculty East-Westphalia, University of Bielefeld, 33615 Bielefeld, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (D.L.); (C.M.); (M.v.d.A.)
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, 6200 Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Centre of General Practice, KU Leuven, 3000 Leuven, Belgium
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11
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Hale L, Higgs C, Gray A, Mann J, Mani R, Sullivan T, Terry J, Keen D, Stokes T. The diabetes community exercise programme plus usual care versus usual care in patients with type 2 diabetes: A randomised, two-arm, parallel, open-label trial. EClinicalMedicine 2022; 46:101361. [PMID: 35360148 PMCID: PMC8961191 DOI: 10.1016/j.eclinm.2022.101361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/15/2022] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background Exercise is important in type 2 diabetes (T2D) management. Focussing on Māori and Pacific people and those from deprived circumstances, the Diabetes Community Exercise Programme (DCEP) was developed to engage people with T2D in exercise. We report the evaluation of whether being offered DCEP (plus usual care) was more effective than usual care in improving glycaemic control at 1-year. Methods A randomised, two-arm, parallel, open-label trial with blinding of outcome assessor and data analyst. Adults (age ≥35 years) with T2D recruited from two New Zealand (NZ) communities were randomised, using opaque sealed envelopes and stratified by centre with random block lengths, to DCEP or usual care. DCEP comprises twice-weekly, two-hour sessions of exercise and education over 12-weeks, followed by a twice-weekly maintenance exercise class. The primary outcome was between-group differences in mean changes of glycated haemoglobin (HbA1c) from baseline to 1-year follow-up with intention-to treat analysis. This trial is registered with the Australian NZ Clinical Trials Registry (ANZCTR): ACTRN12617001624370p and is closed to new participants. Findings From 2018 - 2019, of 294 people screened, 165 (mean age 63·8, SD16·2 years, 56% female, 78·5% European, 14% Māori, 6% Pacific, 27% most deprived) were baseline evaluated, randomised, and analysed at study end (DCEP = 83, control = 82). Multimorbidity (≥2) and polypharmacy (>5 medications) were high (82%, 69%). We found no statistically significant between-groups differences in HbA1c (mmol/mol) change at 15 months (mean 3% higher in DCEP, 95% CI 2% lower to 8% higher, p = 0·23). Twelve-week intervention adherence was good (41% attended >80% available sessions). No adverse events were reported. Interpretation DCEP was not effective in improving glycaemic control, possibly due to insufficient exercise intensity. Our attendance demonstrated DCEP's cultural accessibility. DCEP might be good to engage in exercise marginalised people with high Hb1Ac levels, multimorbidity, and high polypharmacy. Funding Health Research Council of New Zealand.
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Affiliation(s)
- L. Hale
- Centre of Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin 9016, PO Box 56, Dunedin 9054, New Zealand
| | - C. Higgs
- Centre of Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin 9016, PO Box 56, Dunedin 9054, New Zealand
| | - A.R. Gray
- Biostatistics Centre, University of Otago, Dunedin, Otago, New Zealand
| | - J. Mann
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - R. Mani
- Centre of Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin 9016, PO Box 56, Dunedin 9054, New Zealand
| | - T. Sullivan
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - J. Terry
- Centre of Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin 9016, PO Box 56, Dunedin 9054, New Zealand
| | - D. Keen
- Centre of Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin 9016, PO Box 56, Dunedin 9054, New Zealand
| | - T. Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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12
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Prathivadi P, Buckingham P, Chakraborty S, Hawes L, Saha SK, Barton C, Mazza D, Russell G, Sturgiss E. Implementation science: an introduction for primary care. Fam Pract 2022; 39:219-221. [PMID: 34694348 DOI: 10.1093/fampra/cmab125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pallavi Prathivadi
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Philippa Buckingham
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Samantha Chakraborty
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lesley Hawes
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Centre for Antimicrobial Stewardship, Doherty Institute, Melbourne, Australia
| | - Sajal K Saha
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Centre for Antimicrobial Stewardship, Doherty Institute, Melbourne, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Christopher Barton
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Danielle Mazza
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Centre for Antimicrobial Stewardship, Doherty Institute, Melbourne, Australia
| | - Grant Russell
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Elizabeth Sturgiss
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
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13
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Ellis-Smith C, Tunnard I, Dawkins M, Gao W, Higginson IJ, Evans CJ. Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools. BMC Palliat Care 2021; 20:168. [PMID: 34674695 PMCID: PMC8532380 DOI: 10.1186/s12904-021-00845-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022] Open
Abstract
Background Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. Methods A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. Results Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. Conclusion The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00845-9.
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Affiliation(s)
- Clare Ellis-Smith
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.
| | - India Tunnard
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Marsha Dawkins
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Guys & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, UK
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14
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Rommerskirch-Manietta M, Braunwarth JI, Quasdorf T, Manietta C, Rodrigues-Recchia D, Reuther S, Rossmann C, Acet S, Roes M. Organizational Capacity Building in Nursing Facilities to Promote Resident Mobility: A Systematic Review. J Am Med Dir Assoc 2021; 22:2408-2424.e12. [PMID: 34653383 DOI: 10.1016/j.jamda.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/10/2021] [Accepted: 09/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The objective of the present systematic review was to investigate the effects of organizational capacity building interventions on the environment, nursing staff capacity, and mobility of residents in nursing facilities. DESIGN Systematic review. SETTING AND PARTICIPANTS Nursing facilities, staff, and residents. METHODS We conducted a systematic review according to the methods of the Cochrane Collaboration. The systematic review was prospectively registered in the PROSPERO database of systematic reviews (registration number CRD42020202996). We searched for studies in MEDLINE (via PubMed), CINAHL (via EBSCO), the Physiotherapy Evidence Database (PEDro), and the Cochrane Library (07/20). A narrative synthesis was conducted because of the high heterogeneity of the included studies. RESULTS We identified 6747 records and included 14 studies in our review. We clustered the 14 interventions into 3 different categories (environmental modification, nursing staff capacity, and multifactorial interventions). Three studies assessed outcomes at the nursing staff level, and all studies reported outcomes at the resident level. We found highly heterogeneous and inconsistent effects of organizational capacity building on increasing nursing staff capacity and/or resident mobility. CONCLUSIONS AND IMPLICATIONS The findings emphasize the need for further research focusing on an international understanding and definition of organizational capacity building. Additionally, research and intervention development for organizational capacity building interventions to promote resident mobility are needed while applying the framework of the Medical Research Council. Furthermore, studies should assess outcomes regarding the environment and nursing staff to better understand if and how environmental structures and nursing staff capacity effect resident mobility.
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Affiliation(s)
- Mike Rommerskirch-Manietta
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, North Rhine-Westphalia, Germany; Witten/Herdecke University, Faculty of Health, Department of Nursing Science, Witten, North Rhine-Westphalia, Germany.
| | - Jana Isabelle Braunwarth
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, North Rhine-Westphalia, Germany; Witten/Herdecke University, Faculty of Health, Department of Nursing Science, Witten, North Rhine-Westphalia, Germany
| | - Tina Quasdorf
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, North Rhine-Westphalia, Germany; Witten/Herdecke University, Faculty of Health, Department of Nursing Science, Witten, North Rhine-Westphalia, Germany
| | - Christina Manietta
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, North Rhine-Westphalia, Germany; Witten/Herdecke University, Faculty of Health, Department of Nursing Science, Witten, North Rhine-Westphalia, Germany
| | - Daniela Rodrigues-Recchia
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, North Rhine-Westphalia, Germany; Witten/Herdecke University, Faculty of Health, Department of Nursing Science, Witten, North Rhine-Westphalia, Germany
| | - Sven Reuther
- Städtische Seniorenheime Krefeld, Department Organization and Development, Krefeld, North Rhine-Westphalia, Germany
| | - Christin Rossmann
- Federal Centre for Health Education (BZgA), Köln, North Rhine-Westphalia, Germany
| | - Sule Acet
- Federal Centre for Health Education (BZgA), Köln, North Rhine-Westphalia, Germany
| | - Martina Roes
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Site Witten, Witten, North Rhine-Westphalia, Germany; Witten/Herdecke University, Faculty of Health, Department of Nursing Science, Witten, North Rhine-Westphalia, Germany
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15
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Samal L, Fu HN, Camara DS, Wang J, Bierman AS, Dorr DA. Health information technology to improve care for people with multiple chronic conditions. Health Serv Res 2021; 56 Suppl 1:1006-1036. [PMID: 34363220 PMCID: PMC8515226 DOI: 10.1111/1475-6773.13860] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps. DATA SOURCES We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020. STUDY DESIGN We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making. DATA COLLECTION/EXTRACTION METHODS Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers. PRINCIPAL FINDINGS The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality. CONCLUSIONS Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.
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Affiliation(s)
- Lipika Samal
- Brigham and Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Helen N. Fu
- Indiana University Richard M. Fairbanks School of Public HealthIndianapolisINUSA
- Regenstrief InstituteCenter for Biomedical InformaticsIndianapolisINUSA
| | - Djibril S. Camara
- Center for Disease Control and Prevention, Center for Surveillance, Epidemiology, and Laboratory Services (CSELS) Division of Scientific Education and Professional Development, Public Health Informatics Fellowship ProgramAtlantaGeorgiaUSA
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and QualityRockvilleMDUSA
| | - Jing Wang
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and QualityRockvilleMDUSA
- Florida State University College of NursingTallahasseeFloridaUSA
- Health and Aging Policy Fellows Program at Columbia UniversityNew YorkNYUSA
| | - Arlene S. Bierman
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and QualityRockvilleMDUSA
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16
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Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, Boyd KA, Craig N, French DP, McIntosh E, Petticrew M, Rycroft-Malone J, White M, Moore L. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ 2021; 374:n2061. [PMID: 34593508 PMCID: PMC8482308 DOI: 10.1136/bmj.n2061] [Citation(s) in RCA: 1594] [Impact Index Per Article: 531.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Kathryn Skivington
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lynsay Matthews
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sharon Anne Simpson
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Jane M Blazeby
- Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Bristol Biomedical Research Centre, Bristol, UK
| | - Kathleen Anne Boyd
- Health Economics and Health Technology Assessment Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - David P French
- Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mark Petticrew
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Martin White
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Laurence Moore
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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17
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Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, Boyd KA, Craig N, French DP, McIntosh E, Petticrew M, Rycroft-Malone J, White M, Moore L. Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update. Health Technol Assess 2021; 25:1-132. [PMID: 34590577 PMCID: PMC7614019 DOI: 10.3310/hta25570] [Citation(s) in RCA: 163] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. METHODS There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments. RESULTS Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout. LIMITATIONS The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development. CONCLUSIONS This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers. FUTURE WORK We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources. FUNDING This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).
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Affiliation(s)
- Kathryn Skivington
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lynsay Matthews
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sharon Anne Simpson
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter Craig
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Jane M Blazeby
- Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Kathleen Anne Boyd
- Health Economics and Health Technology Assessment Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - David P French
- Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mark Petticrew
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Martin White
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Laurence Moore
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Kelly M, Steed L, Sohanpal R, Pinnock H, Barradell A, Dibao-Dina C, Mammoliti KM, Wileman V, Rowland V, Newton S, Moore A, Taylor S. The TANDEM trial: protocol for the process evaluation of a randomised trial of a complex intervention for anxiety and/or depression in people living with chronic obstructive pulmonary disease (COPD). Trials 2021; 22:495. [PMID: 34311766 PMCID: PMC8313120 DOI: 10.1186/s13063-021-05460-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 07/15/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND TANDEM is a randomised controlled trial of a complex healthcare intervention to improve the psychological and physical health of people living with chronic obstructive pulmonary disease (COPD) and anxiety and/or depression. Based on health psychology theory set out in a logic model, respiratory health professionals were recruited and trained to deliver a cognitive behavioural approach intervention (The TANDEM intervention) under the supervision of senior cognitive behavioural practitioners. Here, we describe the protocol for the process evaluation commissioned alongside the trial. A realist approach that includes attention to describing contexts and mechanisms has been adopted. METHODS We set up a multi-disciplinary team to develop and deliver the process evaluation. The mixed-methods design incorporates quantitative process data; monitoring of intervention fidelity; qualitative interviews with patients, carers, health professionals (facilitators) and clinical supervisors about their perspectives on acceptability of the intervention; and exploration with all stakeholders (including management/policy-makers) on future implementation. Normalisation process theory (NPT) will inform data collection and interpretation with a focus on implementation. Quantitative process data will be analysed descriptively. Qualitative interview data will be analysed before the trial outcomes are known using analytic induction and constant comparison to develop themes. Findings from the different elements will be reported separately and then integrated. CONCLUSION Detailed description and analysis of study processes in a research trial such as TANDEM enables research teams to describe study contexts and mechanisms and to examine the relationship with outcomes. In this way, learning from the trial goes beyond the randomised control trial (RCT) model where effectiveness is prioritised and makes it possible to explore issues arising for post-trial study implementation. TRIAL REGISTRATION ISRCTN ISRCTN59537391 . Registered on 20 March 2017. Trial protocol version 6.0, 22 April 2018. Process evaluation protocol version 4.0, 1 November 2020.
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Affiliation(s)
- Moira Kelly
- Centre for Primary Care and Mental Health, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58, Turner Street, London, E1 2AB, UK.
| | - Liz Steed
- Centre for Primary Care and Mental Health, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58, Turner Street, London, E1 2AB, UK
| | - Ratna Sohanpal
- Centre for Primary Care and Mental Health, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58, Turner Street, London, E1 2AB, UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Amy Barradell
- Department of Respiratory Sciences, College of Life Sciences, NIHR Leicester Biomedical Research Centre- Respiratory Glenfield Hospital, University of Leicester, Groby Road, Leicester, LE3 9QP, UK
| | - Clarisse Dibao-Dina
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, 10 Boulevard Tonnellé, B.P. 3223, 37044, Tours, cedex 1, France
| | - Kristie-Marie Mammoliti
- Birmingham Clinical Trials Unit and WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Vari Wileman
- Centre for Primary Care and Mental Health, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58, Turner Street, London, E1 2AB, UK
| | - Vickie Rowland
- Department of Health & Social Sciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol, BS16 1QY, UK
| | - Sian Newton
- Centre for Primary Care and Mental Health, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58, Turner Street, London, E1 2AB, UK
| | - Anna Moore
- The Education Academy, Barts Health NHS Trust, Royal London Hospital, Whitechapel Road, London, E1 1FR, UK
| | - Stephanie Taylor
- Centre for Primary Care and Mental Health, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58, Turner Street, London, E1 2AB, UK
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Rachamin Y, Grischott T, Neuner-Jehle S. Implementation of a complex intervention to improve hospital discharge: process evaluation of a cluster randomised controlled trial. BMJ Open 2021; 11:e049872. [PMID: 34045217 PMCID: PMC8162085 DOI: 10.1136/bmjopen-2021-049872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To study the implementation of a cluster randomised controlled effectiveness-implementation hybrid trial testing the effectiveness of a medication review at hospital discharge combined with a communication stimulus between hospital physicians (HPs) and general practitioners (GPs) on rehospitalisation of multimorbid older patients. DESIGN Extension of Grant's mixed method process evaluation framework to trials with multilevel clustering. SETTING General internal medicine wards in Swiss hospitals. PARTICIPANTS Convenience samples of 15 chief physicians (of 21 hospitals participating in the effectiveness trial), 60 (74) senior HPs, 65 (164) junior HPs and 187 (411) GPs. IMPLEMENTATION STRATEGY Two-hour teaching sessions for senior HPs on a patient-centred, checklist-guided discharge routine. PROCESS EVALUATION COMPONENTS Data collection on recruitment, delivery and response from chief physicians (semistructured interviews), senior HPs, junior HPs, GPs (surveys) and patients (via HPs). Quantitative data were summarised using descriptive statistics, and interviews analysed using thematic analysis. OUTCOME MEASURES Intervention dose (quantitative), implementation fidelity (qualitative), feasibility and acceptability, facilitators and barriers, implementation support strategies. RESULTS Recruitment of hospitals was laborious but successful, with 21 hospitals recruited. Minimal workload and a perceived benefit for the clinic were crucial factors for participation. Intervention dose was high (95% of checklist activities carried out), but intervention fidelity was limited (discharge letters) or unknown (medication review). Recruitment and retention of patients was challenging, partly due to patient characteristics (old, frail) and the COVID-19 pandemic: Only 612 of the anticipated 2100 patients were recruited, and 31% were lost to follow-up within the first month after discharge. The intervention was deemed feasible and helpful by HPs, and the relevance of the topic appreciated by both HPs and GPs. CONCLUSIONS The results from this evaluation will support interpretation of the findings of the effectiveness study and may inform researchers and policy makers who aim at improving hospital discharge. TRIAL REGISTRATION NUMBER ISRCTN18427377.
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Affiliation(s)
- Yael Rachamin
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Thomas Grischott
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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Kiely B, O'Donnell P, Byers V, Galvin E, Boland F, Smith SM, Connolly D, O'Shea E, Clyne B. Protocol for a mixed methods process evaluation of the LinkMM randomised controlled trial "Use of link workers to provide social prescribing and health and social care coordination for people with complex multimorbidity in socially deprived areas". HRB Open Res 2021; 4:38. [PMID: 37901156 PMCID: PMC10605865 DOI: 10.12688/hrbopenres.13258.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 10/31/2023] Open
Abstract
Background Multimorbidity, defined as two or more chronic conditions is increasing in prevalence and is associated with increased health care use, fragmented care and poorer health outcomes. Link workers are non-health or social care professionals who support people to connect with resources in their community to improve their well-being, a process commonly referred to as social prescribing. The use of link workers in primary care may be an effective intervention in helping those with long-term conditions manage their illness and improve health and well-being, but the evidence base in limited. The LinkMM study is a randomised controlled trial of the effectiveness of link workers based in primary care, providing social prescribing and health and social care coordination for people with multimorbidity. The aim of the LinkMM process evaluation is to investigate the implementation of the link worker intervention, mechanisms of impact and influence of the specific context on these, as per the Medical Research Council framework, using quantitative and qualitative methods. Methods Quantitative data will be gathered from a number of sources including researcher logbooks, participant baseline questionnaires, client management database, and will be analysed using descriptive statistics. Semi structured interviews with participants will investigate their experiences of the intervention. Interviews with link workers, practices and community stakeholders will explore how the intervention was implemented and barriers and facilitators to this. Thematic analysis of interview transcripts will be conducted. Discussion The process evaluation of the LinkMM trial will provide important information allowing a more in-depth understanding of how the intervention worked and lessons for future wider scale implementation.
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Affiliation(s)
- Bridget Kiely
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland, D02Vn51, Ireland
| | - Patrick O'Donnell
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland, Ireland
| | - Vivienne Byers
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland, D02Vn51, Ireland
| | - Emer Galvin
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland, D02Vn51, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland, D02Vn51, Ireland
| | - Susan M. Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland, D02Vn51, Ireland
| | - Deirdre Connolly
- Discipline of Occupational Therapy, Trinity College Dublin, Dublin, Ireland, Ireland
| | - Eamon O'Shea
- School of Business and Economics, National Univeristy of Ireland, Galway, Galway, Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland, D02Vn51, Ireland
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21
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Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients' experience. Br J Gen Pract 2021; 71:e320-e330. [PMID: 33753349 PMCID: PMC7997674 DOI: 10.3399/bjgp21x714293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/15/2020] [Indexed: 11/06/2022] Open
Abstract
Background Patient-centred interventions to help patients with multimorbidity have had mixed results. Aim To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work. Design and setting Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada. Method Patients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention. Results A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes. Conclusion Overall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.
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22
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Leiva-Fernández F, Prados-Torres JD, Prados-Torres A, del-Cura-González I, Castillo-Jimena M, López-Rodríguez JA, Rogero-Blanco ME, Lozano-Hernández CM, López-Verde F, Bujalance-Zafra MJ, Pico-Soler MV, Gimeno-Feliu LA, Poblador-Plou B, Martinez-Cañavate MT, Muth C. Training primary care professionals in multimorbidity management: Educational assessment of the eMULTIPAP course. Mech Ageing Dev 2020; 192:111354. [DOI: 10.1016/j.mad.2020.111354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/11/2020] [Indexed: 11/15/2022]
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Fisher K, Markle-Reid M, Ploeg J, Bartholomew A, Griffith LE, Gafni A, Thabane L, Yous ML. Self-management program versus usual care for community-dwelling older adults with multimorbidity: A pragmatic randomized controlled trial in Ontario, Canada. JOURNAL OF COMORBIDITY 2020; 10:2235042X20963390. [PMID: 33117723 PMCID: PMC7573753 DOI: 10.1177/2235042x20963390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 08/13/2020] [Accepted: 08/31/2020] [Indexed: 12/30/2022]
Abstract
Background: Multimorbidity, the co-existence of 2+ (or 3+) chronic diseases in an individual, is an increasingly common global phenomenon leading to reduced quality of life and functional status, and higher healthcare service use and mortality. There is an urgent need to develop and test new models of care that incorporate the components of multimorbidity interventions recommended by international organizations, including care coordination, interdisciplinary teams, and care plans developed with patients that are tailored to their needs and preferences. Purpose: To determine the effectiveness of a 6-month, community-based, multimorbidity intervention compared to usual home care services for community-dwelling older adults (age 65+ years) with multimorbidity (3+ chronic conditions) that were newly referred to and receiving home care services. Methods: A pragmatic, parallel, two-arm randomized controlled trial evaluated the intervention, which included in-home visits by an interdisciplinary team, personal support worker visits, and monthly case conferences. The study took place in two sites in central Ontario, Canada. Eligible and consenting participants were randomly allocated to the intervention and control group using a 1:1 ratio. The participants, statistician/analyst, and research assistants collecting assessment data were blinded. The primary outcome was the Physical Component Summary (PCS) score of the 12-Item Short-Form health survey (SF-12). Secondary outcomes included the SF-12 Mental Component Summary (MCS) score, Center for Epidemiological Studies of Depression (CESD-10), Generalized Anxiety Disorder (GAD-7), Self-Efficacy for Managing Chronic Disease, and service use and costs. Analysis of covariance (ANCOVA) tested group differences using multiple imputation to address missing data, and non-parametric methods explored service use and cost differences. Results: 59 older adults were randomized into the intervention (n = 30) and control (n = 29) groups. At baseline, groups were similar for the primary outcome and number of chronic conditions (mean of 8.6), but the intervention group had lower mental health status. The intervention was cost neutral and no significant group differences were observed for the primary outcome of PCS from SF-12 (mean difference: −4.94; 95% CI: −12.53 to 2.66; p = 0.20) or secondary outcomes. Conclusion: We evaluated a 6-month, self-management intervention for older adults with multimorbidity. While the intervention was cost neutral in comparison to usual care, it was not found to improve the PCS from SF-12 or secondary health outcomes. Recruitment and retention challenges were significant obstacles limiting our ability to assess intervention effectiveness. Yet, the intervention was grounded in internationally-endorsed recommendations and implemented in a practice setting (home care) viewed as a key upstream resource fostering independence in older adults. These features collectively support the identification of ways to recruit/retain older adults and test alternative implementation strategies for interventions that are based on sound principles of multimorbidity management.
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Affiliation(s)
- Kathryn Fisher
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Maureen Markle-Reid
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jenny Ploeg
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Department of Health, Aging and Society, McMaster University, Hamilton, Ontario, Canada
| | - Amy Bartholomew
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Lee Yous
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
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Scobbie L, Duncan EAS, Brady MC, Thomson K, Wyke S. Facilitators and "deal breakers": a mixed methods study investigating implementation of the Goal setting and action planning (G-AP) framework in community rehabilitation teams. BMC Health Serv Res 2020; 20:791. [PMID: 32843039 PMCID: PMC7447562 DOI: 10.1186/s12913-020-05651-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High quality goal setting in stroke rehabilitation is vital, but challenging to deliver. The G-AP framework (including staff training and a stroke survivor held G-AP record) guides patient centred goal setting with stroke survivors in community rehabilitation teams. We found G-AP was acceptable, feasible to deliver and clinically useful in one team. The aim of this study was to conduct a mixed methods investigation of G-AP implementation in diverse community teams prior to a large-scale evaluation. METHODS We approached Scottish community rehabilitation teams to take part. Following training, G-AP was delivered to stroke survivors within participating teams for 6 months. We investigated staff experiences of G-AP training and its implementation using focus groups and a training questionnaire. We investigated fidelity of G-AP delivery through case note review. Focus group data were analysed using a Framework approach; identified themes were mapped into Normalisation Process Theory constructs. Questionnaire and case note data were analysed descriptively. RESULTS We recruited three teams comprising 55 rehabilitation staff. Almost all staff (93%, 51/55) participated in G-AP training; of those, 80% (n = 41/51) completed the training questionnaire. Training was rated as 'good' or 'very good' by almost all staff (92%, n = 37/41). G-AP was broadly implemented as intended in two teams. Implementation facilitators included - G-AP 'made sense'; repetitive use of G-AP in practice; flexible G-AP delivery and positive staff appraisals of G-AP impact. G-AP failed to gain traction in the third team. Implementation barriers included - delays between G-AP training and implementation; limited leadership engagement; a poor 'fit' between G-AP and the team organisational structure and simultaneous delivery of other goal setting methods. Staff recommended (i) development of training to include implementation planning; (ii) ongoing local implementation review and tailoring, and (iii) development of electronic and aphasia friendly G-AP records. CONCLUSIONS The interaction between G-AP and the practice setting is critical to implementation success or failure. Whilst facilitators support implementation success, barriers can collectively act as implementation "deal breakers". Local G-AP implementation efforts should be planned, monitored and tailored. These insights can inform implementation of other complex interventions in community rehabilitation settings.
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Affiliation(s)
- Lesley Scobbie
- Nursing, Midwifery and Allied Health Profession Research Unit, Govan Mbeki Building, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 OBA, Scotland
- Nursing, Midwifery and Allied Health Professions Research Unit, Unit 13 Scion House, University of Stirling Innovation Park, Stirling, FK9 4NF Scotland
| | - Edward A. S. Duncan
- Nursing, Midwifery and Allied Health Professions Research Unit, Unit 13 Scion House, University of Stirling Innovation Park, Stirling, FK9 4NF Scotland
| | - Marian C. Brady
- Nursing, Midwifery and Allied Health Profession Research Unit, Govan Mbeki Building, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 OBA, Scotland
| | - Katie Thomson
- Nursing, Midwifery and Allied Health Profession Research Unit, Govan Mbeki Building, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 OBA, Scotland
| | - Sally Wyke
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8R2 Scotland
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