ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Role of Health Care Professionals in the Success of Blood Pressure Control Interventions in Patients With Hypertension: A Meta-Analysis

BACKGROUND

Globally, only 13.8% of patients with hypertension have their blood pressure (BP) controlled. Trials testing interventions to overcome barriers to BP control have produced mixed results. Type of health care professional delivering the intervention may play an important role in intervention success. The goal of this meta-analysis is to determine which health care professionals are most effective at delivering BP reduction interventions.

METHODS

We searched Medline and Embase (until December 2023) for randomized controlled trials of interventions targeting barriers to hypertension control reporting who led intervention delivery. One hundred articles worldwide with 116 comparisons and 90 474 participants with hypertension were included. Trials were grouped by health care professional, and the effects of the intervention on systolic and diastolic BP were combined using random effects models and generalized estimating equations.

RESULTS

Pharmacist-led interventions , community health worker-led interventions, and health educator-led interventions resulted in the greatest systolic BP reductions of -7.3 (95% CI, -9.1 to -5.6), -7.1 (95% CI, -10.8 to -3.4), and -5.2 (95% CI, -7.8 to -2.6) mm Hg, respectively. Interventions led by multiple health care professionals, nurses, and physicians also resulted in significant systolic BP reductions of -4.2 (95% CI, -6.1 to -2.4), -3.0 (95% CI, -4.2 to -1.9), and -2.4 (95% CI, -3.4 to -1.5) mm Hg, respectively. Similarly, the greatest diastolic BP reductions were -3.9 (95% CI, -5.2 to -2.5) mm Hg for pharmacist-led and -3.7 (95% CI, -6.6 to -0.8) mm Hg for community health worker-led interventions. In pairwise comparisons, pharmacist were significantly more effective than multiple health care professionals, nurses, and physicians at delivering interventions.

CONCLUSIONS

Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.

Optimizing implementation: elucidating the role of behavior change techniques and corresponding strategies on determinants and implementation performance: a cross-sectional study

INTRODUCTION

Behavior change techniques (BCTs) are considered as active components of implementation strategies, influencing determinants and, ultimately, implementation performance. In our previous Delphi study, experts formulated 'implementation hypotheses', detailing how specific combinations of BCTs and strategies (referred to as BCT-strategy combinations) might influence determinants and guideline implementation within youth care. For example, educational meetings providing instructions on guideline use were hypothesized to enhance practitioners' knowledge and, consequently, guideline implementation. However, these hypotheses have not been verified in practice yet.

METHOD

We conducted a cross-sectional study involving practitioners and management professionals from youth (health)care organizations. Using questionnaires, we obtained data on the presence of BCT-strategy combinations and their perceived influence on determinants and implementation performance. Chi-squared tests and regression analyses were employed to determine the influence of specific BCT-strategy combinations on determinants and implementation performance.

RESULTS

Our analyses included data from 104 practitioners and 34 management professionals. Most of the management professionals indicated that the BCT-strategy combinations positively influenced or had the potential to influence their implementation performance. At the practitioner level, half of the combinations were perceived to have a positive influence on determinants and implementation performance. Furthermore, practitioners who reported the absence of BCT-strategy combinations were more skeptical about their potential influence on determinants and implementation performance.

CONCLUSION

Several BCT-strategy combinations were perceived to improve or potentially improve implementation performance of both practitioners and management professionals. In the development and evaluation of implementation efforts, we advocate for clearly describing the implementation effort's objective and using frameworks that detail the BCTs inducing behavior change, the strategy employed, and the processes driving the observed changes. Understanding these interconnected processes is important in designing targeted, evidence-based behavior change interventions. This understanding optimizes resource allocation and contributes to the overall success of implementation efforts in youth care.

Methodological proposals for developing trustworthy recommendations of integrative Chinese-Western medicine

Background

To refine the methods of developing clinical practice guidelines (CPGs) for integrative Chinese-Western medicine (ICWM), promoting the formation of trustworthy, implementable recommendations that integrate the strengths of Chinese and Western medicine.

Methods

Using a nominal group technique (NGT) approach, a multidisciplinary expert panel was established. The panel identified key methodological issues in ICWM-CPG development through literature review and iterative discussions, and formulated methodological proposals to address these issues. The final set of proposals was achieved through consensus among the panel members.

Results

The collaborative effort resulted in the identification of five pivotal methodological issues and the subsequent establishment of 22 specific recommendations. These encompass strict adherence to renowned standards, such as those proposed by the Institute of Medicine (IOM) and Guidelines International Network (G-I-N), the employment of methodologies like the GRADE approach and RIGHT statement, the strategic constitution of a balanced development group, the adept identification of ICWM-focused clinical inquiries, the nuanced integration of diverse evidence sources, and the detailed crafting of transparent, implementable recommendations.

Conclusions

This study concentrates on the most crucial and prevalent methodological issues in ICWM-CPG development, proposing a series of recommendations. These suggestions result from a multidisciplinary expert consensus, aiming to provide methodological guidance for ICWM-CPG developers, building upon the current foundational methodologies.

Applying the RE-AIM framework to evaluate an educational model to "close the gap" and improve health equity in uncontrolled hypertension

OBJECTIVES

To use the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate an educational model addressing self-management of uncontrolled hypertension.

METHODS

We used a pre-post single cohort design to identify minoritized patients with uncontrolled hypertension (systolic > 160 mmHg and/or diastolic > 100 mmHg). Trained Ambassadors provided telephone outreach, skill-based blood pressure (BP) monitoring, and goal-setting for 4 months. Follow-up occurred at 7 months. We evaluated the initiative using the RE-AIM framework and quantitative analysis for process and outcome measures post-intervention.

RESULTS

Among Black patients (n = 345), the average age was 55.4 years (8.7), half identified as male (n = 173, 50.1 %); many were uninsured (n = 159, 46.1 %). Engagement in calls occurred for 67.8 % (n = 234) of the cohort; monitor distribution was 22.9 % (n = 79); and goal setting occurred for 64 patients. BP improved for 40 % of the cohort (mean pre: 168/98 mmHg, mean post: 150/89 mmHg; p < 0.0001) and 40 % of patients' last known BP was < 140/90.

CONCLUSIONS

RE-AIM evaluation of the Closing the Gap initiative suggests that the model is associated with BP reduction in high-risk Black patients.

PRACTICE IMPLICATIONS

An educational model for patient-centered hypertension management in low-income populations is feasible and addresses self-monitoring barriers.

Feasibility testing of an interprofessional education intervention to support collaborative practice in home care for older stroke survivors with multiple chronic conditions

This mixed-methods study examined the feasibility of implementing a new six-month, theory-based, interprofessional education intervention, and explored its effects and impact on collaborative practice among home care providers caring for older adult stroke survivors (≥65) with multiple chronic conditions. The evaluation utilized a qualitative descriptive and one group repeated measures design which included participant questionnaires, focus groups and field notes. Participants included 37 home care providers (registered nurses, physiotherapists, occupational therapists, personal support workers, care coordinators, and their supervisors) in Ontario, Canada. The intervention was feasible and acceptable to home care providers. Perceived benefits included improved communication and collaboration within teams, enhanced role understanding, increased learning with and from each other, and increased appreciation of all team members' expertise. From 3 to 6 months post initial IPE training, there was a statistically significant improvement in three domains of collaborative practice as measured by the Collaborative Practice Assessment Tool (communication/information exchange; community linkage and coordination of care; decision-making and conflict management) and one domain of collaborative practice, as measured by the 19-item Team Climate Inventory (task orientation). Implications for implementing interprofessional education in home care practice settings are described. Further testing in other populations and settings is warranted.

Guideline adherence in the use of coronary angiography in patients presenting at the emergency department without myocardial infarction - Results from the German ENLIGHT-KHK project

Background

For patients with acute myocardial infarction (AMI), direct coronary angiography (CA) is recommended, while for non-AMI patients, the diagnostic work-up depends on clinical criteria. This analysis provides initial prospective German data for the degree of guideline-adherence (GL) in the use of CA on non-AMI patients presenting at the emergency department (ED) with suspected acute coronary syndrome (ACS) according to the 2015 ESC-ACS-GL. Furthermore the implications of the application of the 2020 ESC-ACS-GL recommendations were evaluated.

Methods

Patient symptoms were identified using a standardized questionnaire; medical history and diagnostic work-up were acquired from health records. In accordance with the 2015 ESC-ACS-GL, CA was considered GL-adherent if intermediate risk criteria (IRC) were present or non-invasive, image-guided testing (NIGT) was pathological.

Results

Between January 2019 and August 2021, 229 patients were recruited across seven centers. Patients presented with chest pain, dyspnea, and other symptoms in 66.7%, 16.2% and 17.1%, respectively, were in mean 66.3 ± 10.5 years old, and 36.3% were female. In accordance with the 2015 ESC-ACS-GL, the use of CA was GL-adherent for 64.0% of the patients. GL-adherent compared to non-adherent use of CA resulted in revascularization more often (44.5% vs. 17.1%, p < 0.001). Applying the 2020 ESC-ACS-GL, 20.4% of CA would remain GL-adherent.

Conclusions

In the majority of cases, the use of CA was adherent to the 2015 ESC-ACS-GL. With regard to the 2020 and 2023 ESC-ACS-GL, efforts to expand the utilization of NIGT are crucial, especially as GL-adherent use of CA is more likely to result in revascularization.(German Clinical Trials Register DRKS00015638; https://drks.de/search/de/trial/DRKS00015638; (registration date: 19 February 2019)).

Ten-Year Review of Antihypertensive Prescribing Practices After Stroke and the Associated Disparities From the Florida Stroke Registry

BACKGROUND

Guideline-based hypertension management is integral to the prevention of stroke. We examine trends in antihypertensive medications prescribed after stroke and assess how well a prescriber's blood pressure (BP) medication choice adheres to clinical practice guidelines (BP-guideline adherence).

METHODS AND RESULTS

The FSR (Florida Stroke Registry) uses statewide data prospectively collected for all acute stroke admissions. Based on established guidelines, we defined optimal BP-guideline adherence using the following hierarchy of rules: (1) use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker as first-line antihypertensive among diabetics; (2) use of thiazide-type diuretics or calcium channel blockers among Black patients; (3) use of beta blockers among patients with compelling cardiac indication; (4) use of thiazide, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, or calcium channel blocker class as first line in all others; (5) beta blockers should be avoided as first line unless there is a compelling cardiac indication. A total of 372 254 cases from January 2010 to March 2020 are in the FSR with a diagnosis of acute ischemic stroke, hemorrhagic stroke, transient ischemic attack, or subarachnoid hemorrhage; 265 409 with complete data were included in the final analysis. Mean age was 70±14 years; 50% were women; and index stroke subtypes were 74% acute ischemic stroke, 11% intracerebral hemorrhage, 11% transient ischemic attack, and 4% subarachnoid hemorrhage. BP-guideline adherence to each specific rule ranged from 48% to 74%, which is below quality standards of 80%, and was lower among Black patients (odds ratio, 0.7 [95% CI, 0.7-0.83]; P<0.001) and those with atrial fibrillation (odds ratio, 0.53 [95% CI, 0.50-0.56]; P<0.001) and diabetes (odds ratio, 0.65 [95% CI, 0.61-0.68]; P<0.001).

CONCLUSIONS

This large data set demonstrates consistently low rates of BP-guideline adherence over 10 years. There is an opportunity for monitoring hypertensive management after stroke.

Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA.

METHODS

The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript.

RESULTS

Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials.

CONCLUSIONS

Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial

BACKGROUND

Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams.

METHODS

The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months.

DISCUSSION

The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05141396 , registered 12/02/2021.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

A Quality Improvement Project to Decrease CLABSIs in Non-ICU Settings

BACKGROUND AND OBJECTIVES

Central line-associated bloodstream infections (CLABSIs) are a common, preventable healthcare-associated infection. In our 3-hospital health system, CLABSI rates in non-intensive care unit (ICU) settings were above the internal target rate of zero. A robust quality improvement (QI) project to reduce non-ICU CLABSIs was undertaken by a team of Doctor of Nursing Practice (DNP)-prepared nurse leaders enrolled in a post-DNP Quality Implementation Scholars program and 2 QI experts. Based on a review of the literature and local root cause analyses, the QI team implemented the evidence-based practice of using 2% chlorhexidine gluconate (CHG) cloths for daily bathing for non-ICU patients with a central line.

METHODS

A pre-post-design was used for this QI study. CHG bathing was implemented using multifaceted educational strategies that included an e-learning module, printed educational materials, educational outreach, engagement of unit-based CLABSI champions, and an electronic reminder in the electronic health record. Generalized linear mixed-effects models were used to assess the change in CLABSI rates before and after implementation of CHG bathing. CLABSI rates were also tracked using statistical process control (SPC) charts to monitor stability over time. CHG bathing documentation compliance was audited as a process measure. These audit data were provided to unit-based leadership (nurse managers and clinical team leaders) on a monthly basis. A Qualtrics survey was also disseminated to nursing leadership to evaluate their satisfaction with the CHG bathing implementation processes.

RESULTS

Thirty-four non-ICU settings participated in the QI study, including general medical/surgical units and specialty areas (oncology, neurosciences, cardiac, orthopedic, and pediatrics). While the change in CLABSI rates after the intervention was not statistically significant ( b = -0.35, P = .15), there was a clinically significant CLABSI rate reduction of 22.8%. Monitoring the SPC charts demonstrated that CLABSI rates remained stable after the intervention at all 3 hospitals as well as the health system. CHG bathing documentation compliance increased system-wide from 77% (January 2020) to 94% (February 2021). Overall, nurse leaders were satisfied with the CHG bathing implementation process.

CONCLUSIONS

To sustain this practice change in non-ICU settings, booster sessions will be completed at least on an annual basis. This study provides further support for using CHG cloths for daily patient bathing in the non-ICU setting.

Coordinated Care to Optimize Cardiovascular Preventive Therapies in Type 2 Diabetes: A Randomized Clinical Trial

Importance

Evidence-based therapies to reduce atherosclerotic cardiovascular disease risk in adults with type 2 diabetes are underused in clinical practice.

Objective

To assess the effect of a coordinated, multifaceted intervention of assessment, education, and feedback vs usual care on the proportion of adults with type 2 diabetes and atherosclerotic cardiovascular disease prescribed all 3 groups of recommended, evidence-based therapies (high-intensity statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and sodium-glucose cotransporter 2 [SGLT2] inhibitors and/or glucagon-like peptide 1 receptor agonists [GLP-1RAs]).

Design, Setting, and Participants

Cluster randomized clinical trial with 43 US cardiology clinics recruiting participants from July 2019 through May 2022 and follow-up through December 2022. The participants were adults with type 2 diabetes and atherosclerotic cardiovascular disease not already taking all 3 groups of evidence-based therapies.

Interventions

Assessing local barriers, developing care pathways, coordinating care, educating clinicians, reporting data back to the clinics, and providing tools for participants (n = 459) vs usual care per practice guidelines (n = 590).

Main Outcomes and Measures

The primary outcome was the proportion of participants prescribed all 3 groups of recommended therapies at 6 to 12 months after enrollment. The secondary outcomes included changes in atherosclerotic cardiovascular disease risk factors and a composite outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization (the trial was not powered to show these differences).

Results

Of 1049 participants enrolled (459 at 20 intervention clinics and 590 at 23 usual care clinics), the median age was 70 years and there were 338 women (32.2%), 173 Black participants (16.5%), and 90 Hispanic participants (8.6%). At the last follow-up visit (12 months for 97.3% of participants), those in the intervention group were more likely to be prescribed all 3 therapies (173/457 [37.9%]) vs the usual care group (85/588 [14.5%]), which is a difference of 23.4% (adjusted odds ratio [OR], 4.38 [95% CI, 2.49 to 7.71]; P < .001) and were more likely to be prescribed each of the 3 therapies (change from baseline in high-intensity statins from 66.5% to 70.7% for intervention vs from 58.2% to 56.8% for usual care [adjusted OR, 1.73; 95% CI, 1.06-2.83]; ACEIs or ARBs: from 75.1% to 81.4% for intervention vs from 69.6% to 68.4% for usual care [adjusted OR, 1.82; 95% CI, 1.14-2.91]; SGLT2 inhibitors and/or GLP-1RAs: from 12.3% to 60.4% for intervention vs from 14.5% to 35.5% for usual care [adjusted OR, 3.11; 95% CI, 2.08-4.64]). The intervention was not associated with changes in atherosclerotic cardiovascular disease risk factors. The composite secondary outcome occurred in 23 of 457 participants (5%) in the intervention group vs 40 of 588 participants (6.8%) in the usual care group (adjusted hazard ratio, 0.79 [95% CI, 0.46 to 1.33]).

Conclusions and Relevance

A coordinated, multifaceted intervention increased prescription of 3 groups of evidence-based therapies in adults with type 2 diabetes and atherosclerotic cardiovascular disease.

Trial Registration

ClinicalTrials.gov Identifier: NCT03936660.

Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure

PURPOSE OF REVIEW

To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF).

RECENT FINDINGS

There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps.

SUMMARY

Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.

Development and assessment of a low literacy, pictographic asthma action plan with clinical automation to enhance guideline-concordant care for children with asthma

OBJECTIVE

Asthma is characterized by reversible pulmonary symptoms, frequent hospitalizations, poor quality of life, and varied treatment. Parents with low health literacy (HL) is linked to poor asthma outcomes in children. Recent practice updates recommended inhaled corticosteroids for the management of persistent asthma, but guideline-concordant care is suboptimal. Our aim was to develop and assess an Asthma Action Plan (AAP) that could serve as an individualized plan for low HL families and facilitate guideline-concordant care for clinicians.

METHODS

We followed the National Institute of Health 5-step "Clear & Simple" approach to develop the Uniformed Services AAP. Our AAP included symptom pictographs (dyspnea, cough, sleep, activity) and guideline-concordant clinical automation tools. Caregivers assessed the pictograms for validity (transparency of ≥ 85%; translucency score ≥ 5; and ≥ 85% recall). Readability was assessed using 7 formulas. (<6th Grade was acceptable). Comprehensibility, design quality, and usefulness was assessed by caregivers using the Consumer Information Rating Form (CIRF) (>80% was acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (>80% was acceptable). Suitability was assessed by clinicians using the modified Suitability Assessment of Materials (SAM) instrument (>70% was superior).

RESULTS

All 12 pictograms were validated (N = 118 respondents). Readability demonstrated a 4th grade level. Overall CIRF percentile score = 80.4%. Understandability and Actionability = 100%. Suitability score = 75%.

CONCLUSIONS

Our AAP was formally endorsed by the Allergy & Asthma Network. The Uniformed Services AAP is a novel tool with embedded clinical automation that can address low HL and enhance guideline-concordant care.

Improving Skin Care Protocol Use in the Intensive Care Unit to Reduce Hospital-Acquired Pressure Injuries

BACKGROUND

Patients in the intensive care unit have the highest rate of hospital-acquired pressure injuries (HAPIs). In the United States, treatment of HAPIs costs an estimated $9.1 to $11.6 billion annually, with each occurrence adding an average of $10 708 to a patient's total hospital cost. In addition to their financial impact, pressure injuries negatively affect patients physically, socially, and psychologically and are associated with increased morbidity and mortality.

OBJECTIVE

An intensive care unit had 42 HAPIs during a single fiscal year, with 45% of them related to lack of adherence to the institution's established evidence-based skin care protocol. This project was conducted to increase adherence to the protocol and thus reduce the incidence of HAPIs in the unit.

METHODS

This quality improvement initiative featured an evidence-based multifaceted intervention to increase adherence to the skin care protocol. A review of medical records was used to determine general skin care protocol adherence and to measure the monthly incidence of HAPIs in the unit.

RESULTS

The number of HAPIs in the unit decreased from 33 in the preintervention period to 11 in the postintervention period, a reduction of 67%. The rate of general skin care protocol adherence improved to as high as 76% by the end of the postintervention period.

CONCLUSION

Use of an evidence-based multifaceted intervention can improve adherence to a skin care protocol in the intensive care unit, resulting in a reduced incidence of HAPIs and improved patient outcomes.

Implementation science in nursing education research: An exemplar

INTRODUCTION

Using evidence-based teaching approaches can improve nursing students' learning. However, variation in how - or if - these approaches are implemented by faculty and nursing educators is prevalent. A thorough, applied understanding of how evidence-based teaching approaches can best be implemented in the educational setting is lacking.

OBJECTIVES

The purpose of this project was to use an implementation science framework to implement and evaluate the quality of a doctor of nursing practice (DNP) course before and after implementing evidence-based revisions to course delivery and composition.

DESIGN

A pre/post design was used to evaluate course outcomes following implementation of evidence-based teaching approaches.

SETTING

A small, private university in the southeastern United States.

PARTICIPANTS

Students who enrolled in a DNP healthcare quality improvement course.

METHODS

An implementation science framework for integrating evidence-based teaching approaches was used to guide this project. Revisions were made to a DNP course, with evidence-based teaching approaches implemented using strategies including a dedicated course facilitator, faculty education, interactive assistance to course faculty, and detailed rubrics to ensure consistency in grading between sections. Outcomes included course evaluation scores, qualitative student comments, and student engagement measured via the average number of discussion board posts authored and read.

RESULTS

After using the implementation science framework to translate evidence-based teaching approaches, there was a statistically significant improvement in three course evaluation questions and the overall course mean. Qualitative comments showed that students found the revisions beneficial to their learning. There was no change in student engagement.

CONCLUSIONS

Using a structured implementation science framework and plan to translate and evaluate evidence-based teaching approaches resulted in significant improvements in course outcomes. Nurse educators should consider using an implementation framework to guide course revisions.

Translating guidelines into practice via implementation science: an update in lipidology

PURPOSE OF REVIEW

Guidelines provide recommendations for clinicians based on the best available evidence and informed by clinical expertise. These recommendations often fail to be utilized by clinicians hindering the translation of evidence into practice. The purpose of this review is to describe novel ways in which implementation science has been used to improve translation of guidelines into clinical practice in the field of lipidology.

RECENT FINDINGS

We searched PubMed for articles related to guideline implementation in lipidology published in 2021 and 2022. Identified articles were categorized into three domains: first, poor uptake of guideline recommendations in practice; second, implementation science as a solution to improve care; and third, examples of how implementation science can be incorporated into guidelines.

SUMMARY

The field of lipidology has identified that many guideline recommendations fail to be translated into practice and has started to utilize methods from implementation science to assess ways to shrink this gap. Future work should focus on deploying tools from implementation science to address current gaps in guideline development. Such as, developing a systematic approach to restructure guideline recommendations so they are implementable in practice and aid in clinicians' ability to easily translate them into practice.

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial

BACKGROUND

Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown.

METHODS

The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems).

DISCUSSION

The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

Evaluating the Implementation of Evidence-based Kidney Nutrition Practice Guidelines: The AUGmeNt Study Protocol

Evidence-based nutrition practice guidelines (EBNPGs) inform registered dietitian nutritionist (RDN) care for patients with chronic kidney disease grade 5 treated by dialysis; however, there has been little evaluation of best practices for implementing EBNPGs. In this effectiveness-implementation hybrid study with a quasi-experimental design, United States RDNs in hemodialysis clinics will document initial and follow-up nutrition care for patients with chronic kidney disease grade 5 treated by dialysis using the Academy of Nutrition and Dietetics Health Informatics Infrastructure before and after being randomly assigned to a training model: (1) EBNPG knowledge training or (2) EBNPG knowledge training plus an implementation toolkit. The aims of the study include examining congruence of RDN documentation of nutrition care with the EBNPG; describing common RDN-reported EBNPG acceptability, adoption, and adaptation issues; and determining the feasibility of estimating the impact of RDN care on nutrition-related patient outcomes. The AUGmeNt study can inform effective development and implementation of future EBNPGs. Keywords: Chronic kidney diseases; medical nutrition therapy; implementation science; clinical practice guideline; nutrition care process terminology; dietitian.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Effect of Mailing Educational Material to Patients With Atrial Fibrillation and Their Clinicians on Use of Oral Anticoagulants: A Randomized Clinical Trial

IMPORTANCE

Only about half of patients with atrial fibrillation (AF) who are at increased risk for stroke are treated with an oral anticoagulant (OAC), despite guideline recommendations for their use. Educating patients with AF about prevention of stroke with OACs may enable them as agents of change to initiate OAC treatment.

OBJECTIVE

To determine whether an educational intervention directed to patients and their clinicians stimulates the use of OACs in patients with AF who are not receiving OACs.

DESIGN, SETTING, AND PARTICIPANTS

The Implementation of a Randomized Controlled Trial to Improve Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation (IMPACT-AFib) trial was a prospective, multicenter, open-label, pragmatic randomized clinical trial conducted from September 25, 2017, to May 1, 2019, embedded in health plans that participate in the US Food and Drug Administration's Sentinel System. It used the distributed database comprising health plan members to identify eligible patients, their clinicians, and outcomes. IMPACT-AFib enrolled patients with AF, a CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score of 2 or more, no evidence of OAC prescription dispensing in the preceding 12 months, and no hospitalization-related bleeding event within the prior 6 months.

INTERVENTIONS

Randomization to a single mailing of patient and/or clinician educational materials vs control.

MAIN OUTCOMES AND MEASURES

Analysis was performed on a modified intention-to-treat basis. The primary end point was the proportion of patients with at least 1 OAC prescription dispensed or at least 4 international normalized ratio test results within 1 year of the intervention.

RESULTS

Among 47 333 patients, there were 24 909 men (52.6%), the mean (SD) age was 77.9 (9.7) years, mean (SD) CHA2DS2-VASc score was 4.5 (1.7), 22 404 patients (47.3%) had an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more, and 8890 patients (18.8%) had a history of hospitalization for bleeding. There were 2328 of 23 546 patients (9.9%) in the intervention group with initiation of OAC at 1 year compared with 2330 of 23 787 patients (9.8%) in the control group (adjusted OR, 1.01 [95% CI, 0.95-1.07]; P = .79).

CONCLUSIONS AND RELEVANCE

Among a large population with AF with a guideline indication for OACs for stroke prevention who were randomized to a mailed educational intervention or to usual care, there was no clinically meaningful, numerical, or statistically significant difference in rates of OAC initiation. More-intensive interventions are needed to try and address the public health issue of underuse of anticoagulation for stroke prevention among patients with AF.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03259373.

Implementation strategies for knowledge products in primary healthcare: a systematic review of systematic reviews (Preprint)

Background

The underuse or overuse of knowledge products leads to waste in health care, and primary care is no exception.

Objective

This study aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.

Methods

We performed a systematic review (SR) of SRs using the Cochrane systematic approach to include eligible SRs. The inclusion criteria were any primary care contexts, health care professionals and patients, any Effective Practice and Organization of Care implementation strategies of specified knowledge products, any comparators, and any implementation outcomes based on the Proctor framework. We searched the MEDLINE, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019 without any restrictions. We searched the references of the included SRs. Pairs of reviewers independently performed selection, data extraction, and methodological quality assessment by using A Measurement Tool to Assess Systematic Reviews 2. Data extraction was informed by the Effective Practice and Organization of Care taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results by using a narrative synthesis.

Results

Of the 11,101 records identified, 81 (0.73%) SRs were included. Of these 81, a total of 47 (58%) SRs involved health care professionals alone. Moreover, 15 SRs had a high or moderate methodological quality. Most of them addressed 1 type of knowledge product (56/81, 69%), common clinical practice guidelines (26/56, 46%) or management, and behavioral or pharmacological health interventions (24/56, 43%). Mixed strategies were used for implementation (67/81, 83%), predominantly education-based (meetings in 60/81, 74%; materials distribution in 59/81, 73%; and academic detailing in 45/81, 56%), reminder (53/81, 36%), and audit and feedback (40/81, 49%) strategies. Education meetings (P=.13) and academic detailing (P=.11) seemed to be used more when the population was composed of health care professionals alone. Improvements in the adoption of knowledge products were the most commonly measured outcome (72/81, 89%). The evidence level was reported in 12% (10/81) of SRs on 62 outcomes (including 48 improvements in adoption), of which 16 (26%) outcomes were of moderate or high level.

Conclusions

Clinical practice guidelines and management and behavioral or pharmacological health interventions are the most commonly implemented knowledge products and are implemented through the mixed use of educational, reminder, and audit and feedback strategies. There is a need for a strong methodology for the SR of randomized controlled trials to explore their effectiveness and the entire cascade of implementation outcomes.

Survey of Primary Care Physicians' Screening and Treatment Practices for Prediabetes in Saudi Arabia

Background Prediabetes is defined as a condition in which glucose levels do not fulfill the criteria for type 2 diabetes mellitus (T2DM), indicating that the patient is at an increased risk of developing T2DM. The risk of developing T2DM can be decreased by adequately managing prediabetes. This study aimed to assess screening and therapeutic approaches to prediabetes among primary care physicians in Saudi Arabia because there is little contemporary data available on this topic. Methodology A cross-sectional study was performed among primary care physicians in Saudi Arabia. The participants completed a validated online survey questionnaire via Google Forms. Data collected included participants' demographic information, knowledge of T2DM risk factors, and opinions and beliefs on prediabetes management. Results In total, 155 primary care physicians responded to the questionnaire; 51% were male, 18.7% worked in Riyadh City, and 81.3% specialized in family medicine. Most study respondents (71.9%) were residents, and 64.5% worked for the Ministry of Health. Overall, 93.5% of the respondents had completed part of their postgraduate training in Saudi Arabia. Moreover, 27.7% of the respondents were aware of all nine risk factors associated with T2DM. The correct fasting glucose and hemoglobin A1c ranges for the diagnosis of prediabetes were identified by 50% and 43.6% of participants, respectively. Most respondents believed lifestyle modification and metformin to be the most effective management approaches to prediabetes, whereas lack of motivation toward lifestyle changes was deemed to be a major barrier. Conclusions We found significant gaps in primary care physicians' knowledge regarding prediabetes in Saudi Arabia, contributing to underscreening of the condition and undertreatment. Identifying these gaps is essential for focussing educational endeavors toward primary care physicians.

Tracking Blood Pressure Control Performance and Process Metrics in 25 US Health Systems: The PCORnet Blood Pressure Control Laboratory

Background The National Patient-Centered Clinical Research Network Blood Pressure Control Laboratory Surveillance System was established to identify opportunities for blood pressure (BP) control improvement and to provide a mechanism for tracking improvement longitudinally. Methods and Results We conducted a serial cross-sectional study with queries against standardized electronic health record data in the National Patient-Centered Clinical Research Network (PCORnet) common data model returned by 25 participating US health systems. Queries produced BP control metrics for adults with well-documented hypertension and a recent encounter at the health system for a series of 1-year measurement periods for each quarter of available data from January 2017 to March 2020. Aggregate weighted results are presented overall and by race and ethnicity. The most recent measurement period includes data from 1 737 995 patients, and 11 956 509 patient-years were included in the trend analysis. Overall, 15% were Black, 52% women, and 28% had diabetes. BP control (<140/90 mm Hg) was observed in 62% (range, 44%-74%) but varied by race and ethnicity, with the lowest BP control among Black patients at 57% (odds ratio, 0.79; 95% CI, 0.66-0.94). A new class of antihypertensive medication (medication intensification) was prescribed in just 12% (range, 0.6%-25%) of patient visits where BP was uncontrolled. However, when medication intensification occurred, there was a large decrease in systolic BP (≈15 mm Hg; range, 5-18 mm Hg). Conclusions Major opportunities exist for improving BP control and reducing disparities, especially through consistent medication intensification when BP is uncontrolled. These data demonstrate substantial room for improvement and opportunities to close health equity gaps.

Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association

Among the estimated 6.2 million Americans living with heart failure (HF), ≈5%/y may progress to advanced, or stage D, disease. Advanced HF has a high morbidity and mortality, such that early recognition of this condition is important to optimize care. Delayed referral or lack of referral in patients who are likely to derive benefit from an advanced HF evaluation can have important adverse consequences for patients and their families. A 2-step process can be used by practitioners when considering referral of a patient with advanced HF for consideration of advanced therapies, focused on recognizing the clinical clues associated with stage D HF and assessing potential benefits of referral to an advanced HF center. Although patients are often referred to an advanced HF center to undergo evaluation for advanced therapies such as heart transplantation or implantation of a left ventricular assist device, there are other reasons to refer, including access to the infrastructure and multidisciplinary team of the advanced HF center that offers a broad range of expertise. The intent of this statement is to provide a framework for practitioners and health systems to help identify and refer patients with HF who are most likely to derive benefit from referral to an advanced HF center.

Incorporating SGLT2i and GLP-1RA for Cardiovascular and Kidney Disease Risk Reduction: Call for Action to the Cardiology Community

Multiple sodium glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have been shown to impart significant cardiovascular and kidney benefits, but are underused in clinical practice. Both SGLT-2i and GLP-1RA were first studied as glucose-lowering drugs, which may have impeded uptake by cardiologists in the wake of proven cardiovascular efficacy. Their significant effect on cardiovascular and kidney outcomes, which are largely independent of glucose-lowering effects, must drive a broader use of these drugs. Cardiologists are 3 times more likely than endocrinologists to see patients with both type 2 diabetes and cardiovascular disease, thus they are ideally positioned to share responsibility for SGLT-2i and GLP-1RA treatment with primary care providers. In order to increase adoption, SGLT-2i and GLP-1RA must be reframed as primarily cardiovascular and kidney disease risk-reducing agents with a side effect of glucose-lowering. Coordinated and multifaceted interventions engaging clinicians, patients, payers, professional societies, and health systems must be implemented to incentivize the adoption of these medications as part of routine cardiovascular and kidney care. Greater use of SGLT-2i and GLP-1RA will improve outcomes for patients with type 2 diabetes at high risk for cardiovascular and kidney disease.

Strategies for the implementation of best practice guidelines in operating theatres: An integrative literature review

Best practice guidelines (BPGs) exist for operating theatre (OT), but strategies to implement them are lacking. To address the gap, an integrative review was undertaken to identify strategies which can be used to implement BPGs in OT. This article aimed to summarise the best existing literature in order to identify and describe strategies for the implementation of BPGs in OT. An extensive search was undertaken to include relevant literature from February 2005 to March 2020 using the following databases: CINAHL, Medline, Biomed Central, Academic Search Complete and Health Source: Nursing/Academic Edition (EBSCOhost) and the Cochrane library. This integrative literature review followed the methodology proposed by Whittemore and Knafl, namely: (1) identification of the research problem, (2) search of the literature, (3) evaluation of the data, (4) analysis of the data and (5) presentation of the results. On completion of the critical appraisal, 15 (n = 15) articles met the inclusion criteria and relevant data were synthesised. The review identified six strategies facilitating implementation of BPGs in OT, namely, communication, education materials and mass media, academic detailing, opinion leaders, audit and feedback, and teamwork and collaboration. The review validated strategies for the implementation of BPGs in OT. Implementation of BPGs is essential to both provide and improve patient care and to benefit health outcomes. This review is expected to contribute to the provision of strategies to implement BPGs in OT.

Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates.

METHODS

A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability.

RESULTS

Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates.

CONCLUSIONS

Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.

Increase and Change in the Pattern of Antibiotic Use in Serbia (2010-2019)

The aim of this study was to determine and describe trends in antibiotics utilization in Serbia over a ten-year period. Data were retrieved from publicly available annual reports (2010-2019). The results were expressed as Defined Daily Dose (DDD) per 1000 inhabitants per day (DID). All calculations were performed using the DDD values for the 2020 Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) version for each year of the study, to account for the DDD changes during the study period. Antibiotics were classified using the WHO Access, Watch, Reserve (AWaRe) classification. Total utilization of antibacterials for systemic use increased from 17.25 DID in 2010 to 28.65 DID in 2019. A statistically significant increasing trend in the use of the Watch category antibiotics was observed. A tendency towards use of broad-spectrum antibiotics, apparent by a statistically significant increase in the rate of utilization of broad-spectrum macrolides, quinolones and third-generation cephalosporins vs. narrow-spectrum ones, as well as a significant increasing trend in the use of quinolones was identified. Total antibiotic utilization was found to be well above the European average. Several specific problem areas were identified, which requires further efforts to improve antibiotic prescribing. The present study provides the information needed to facilitate antibiotic stewardship in Serbia further and proposes specific interventions to optimize antibiotic use in Serbia.

How Do We Incorporate Polygenic Risk Scores in Cardiovascular Disease Risk Assessment and Management?

PURPOSE OF REVIEW

The potential of polygenic risk scores (PRS) to improve atherosclerotic cardiovascular disease (ASCVD) risk assessment and management has stoked significant interest in their incorporation into clinical management. The goal of this review is to apprise the readers of the latest developments and evidence of PRS readiness for clinical integration. We also discuss current limitations that must be addressed before PRS can be implemented into routine clinical practice.

RECENT FINDINGS

PRS have been shown to improve risk stratification for ASCVD and to identify patients who may derive increased benefit from primary and secondary prevention. Risk captured by PRS appears largely independent of traditional risk factors and can be ascertained at birth, prior to the development of traditional clinical risk factors. Genetic risk is modifiable through lifestyle modifications and medications. PRS offers a valuable way to improve early identification of actionable CVD risk. However, further work is needed before PRS can be implemented clinically.

Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned

OBJECTIVE

To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention.

MATERIALS AND METHODS

The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing.

RESULTS

For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P < .001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P < .001).

CONCLUSION

The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.

Identifying Implementation Strategies That Address Barriers and Facilitate Implementation of Digital Interventions in HIV Primary Care Settings: Results from the Pilot Implementation of Positive Health Check

We used the 1-month pilot implementation of Positive Health Check, a brief web-based video counseling intervention that supports patients with HIV attending HIV primary care clinics, to exemplify how studying implementation strategies earlier in the evidence-generation process can improve implementation outcomes in later pragmatic trials. We identified how implementation strategies were operationalized and the barriers and facilitators these strategies addressed using multiple data sources, including adapted implementation procedures and weekly structured interviews conducted with 9 key stakeholders in 4 HIV primary care clinics. Nineteen of 73 discrete implementation strategies for clinical innovations were used in the pilot implementation of Positive Health Check. Clinic staff reported 17 barriers and facilitators related to the clinic environment, patient population, intervention characteristics, and training and technical assistance. Identifying the link between strategies, barriers, and facilitators helped plan for a subsequent larger multisite pragmatic trial.

Critical appraisal of the quality of clinical practice guidelines for idiopathic pulmonary fibrosis

Background

Clinical practice guidelines (CPGs) have long served as an essential tool for clinicians to rationalize their treatment in practice. However, the quality of guidelines varies greatly. The present study aimed to analyze high-quality CPGs of idiopathic pulmonary fibrosis (IPF) and highlight the potential for further improvement.

Methods

Three guideline developers’ websites, PubMed, Embase, and Web of Science, as well as a public search engine, Google Scholar, were searched to retrieve CPGs regarding the management of IPF. The methodology and reporting quality of retrieved CPGs were assessed using the validated Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist.

Results

Twelve IPF CPGs were reviewed, among which 7 (58.3%) were considered as “recommended” and 1 (8.3%) as “recommended with modifications”. Among the 6 domains of AGREE II, scope and purpose (70.99%) and clarity of presentation (68.06%) were considered to be the fields in which CPGs performed best, evidenced by the highest mean AGREE II scores. The domains in which the reviewed CPGs received the lowest mean scores were rigor of development (50.87%) and applicability (34.14%). The intraclass correlation coefficient scores were excellent in each domain. The basic information domain received the highest overall reporting rate in the 7 domains of the RIGHT checklist; the other 6 domains had a full reporting rate of <50%. Eight items had a satisfactory level of reporting, whereas 14 items had poor reporting according to the RIGHT checklist. Correlation analysis revealed a highly positive correlation between the methodology and reporting quality of CPGs for IPF (r=0.872).

Conclusions

The methodological quality of selected IPF CPGs fluctuated greatly, and the full reporting rate was found to be quite low in some domains. In the future, we should focus not only on improving the methodological quality in the development of guidelines, but also on the reporting quality of guidelines.

Understanding the Complexity of Heart Failure Risk and Treatment in Black Patients

Although care of patients with heart failure (HF) has improved in the past decade, important disparities in HF outcomes persist based on race/ethnicity. Age-adjusted HF-related cardiovascular disease death rates are higher for Black patients, particularly among young Black men and women whose rates of death are 2.6- and 2.97-fold higher, respectively, than White men and women. Similarly, the rate of HF hospitalization for Black men and women is nearly 2.5-fold higher when compared with Whites, with costs that are significantly higher in the first year after HF hospitalization. While the relative rate of HF hospitalization has improved for other race/ethnic minorities, the disparity in HF hospitalization between Black and White patients has not decreased during the last decade. Although access to care and socioeconomic status have been traditional explanations for the observed racial disparities in HF outcomes, contemporary data suggest that novel factors including genetic susceptibility as well as social determinants of health and implicit bias may play a larger role in health outcomes than previously appreciated. The purpose of this review is to describe the complex interplay of factors that influence racial disparities in HF incidence, prevalence, and disease severity, with a highlight on evolving knowledge that will impact the clinical care and address future research needs to improve HF disparities in Blacks.

A Conceptual Framework to Study the Implementation of Clinical Decision Support Systems (BEAR): Literature Review and Concept Mapping

Background

The implementation of clinical decision support systems (CDSSs) as an intervention to foster clinical practice change is affected by many factors. Key factors include those associated with behavioral change and those associated with technology acceptance. However, the literature regarding these subjects is fragmented and originates from two traditionally separate disciplines: implementation science and technology acceptance.

Objective

Our objective is to propose an integrated framework that bridges the gap between the behavioral change and technology acceptance aspects of the implementation of CDSSs.

Methods

We employed an iterative process to map constructs from four contributing frameworks—the Theoretical Domains Framework (TDF); the Consolidated Framework for Implementation Research (CFIR); the Human, Organization, and Technology-fit framework (HOT-fit); and the Unified Theory of Acceptance and Use of Technology (UTAUT)—and the findings of 10 literature reviews, identified through a systematic review of reviews approach.

Results

The resulting framework comprises 22 domains: agreement with the decision algorithm; attitudes; behavioral regulation; beliefs about capabilities; beliefs about consequences; contingencies; demographic characteristics; effort expectancy; emotions; environmental context and resources; goals; intentions; intervention characteristics; knowledge; memory, attention, and decision processes; patient–health professional relationship; patient’s preferences; performance expectancy; role and identity; skills, ability, and competence; social influences; and system quality. We demonstrate the use of the framework providing examples from two research projects.

Conclusions

We proposed BEAR (BEhavior and Acceptance fRamework), an integrated framework that bridges the gap between behavioral change and technology acceptance, thereby widening the view established by current models.

SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation

Background:

Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.

Methods and Results:

We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA 2 DS 2 -VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively ( P =0.21).

Conclusions:

Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov . Unique identifier: NCT03583008.

Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial

Background

Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs).

Methods

This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs’ EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes.

Results

Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes.

Conclusions

Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics’ ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs.

Trial registration

ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

Integrating Lean Thinking and Implementation Science Determinants Checklists for Quality Improvement: A Scoping Review

It is not known how often lean tools and implementation determinants frameworks or checklists are used concurrently in health care quality improvement activities. The authors systematically reviewed the literature for studies that used a lean tool along with an implementation science determinants framework (January 1999 through August 2018). Seven studies (8 publications) were identified, inclusive of 2 protocols and 6 research articles across multiple continents. All included studies used the consolidated framework for implementation research as their implementation science determinants framework. Lean tools included in more than 1 publication were process mapping (4 publications), process redesign (3 publications), and 5S standardization (2 publications). Only 1 study proposed using a lean tool concurrently with an implementation science determinants framework in the design and execution of the QI project. Few published studies utilize both an implementation science determinants framework or checklist and 1 or more lean tool in their study design.

Patient, Provider, and Practice Characteristics Associated With Sacubitril/Valsartan Use in the United States

Background Current guidelines recommend sacubitril/valsartan for patients with heart failure with reduced ejection fraction, but the rate of adoption in the United States has been slow. Methods and Results Using data from CHAMP-HF (Change the Management of Patients With Heart Failure), we described current sacubitril/valsartan use and identified patient, provider, and practice characteristics associated with its use. We considered patients to be on sacubitril/valsartan if they were prescribed it before enrollment or initiated on it at the baseline visit. We excluded patients with a contraindication to sacubitril/valsartan and practices with <10 patients enrolled. Of 4216 patients from 121 sites, 616 (15%) were prescribed sacubitril/valsartan, 2506 (59%) an angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), and 1094 (26%) neither. Patients prescribed sacubitril/valsartan were younger (63 years versus 66 years ACE inhibitor/ARB versus 69 years neither, P<0.001), less likely to have chronic kidney disease (15% versus 17% ACE inhibitor/ARB versus 30% neither, P<0.001), more likely to have cardiac resynchronization therapy (12% versus 7% ACE inhibitor/ARB versus 7% neither, P<0.001), and had lower ejection fraction (27% versus 30% ACE inhibitor/ARB versus 30% neither, P<0.001). Larger practices, based on number of cardiologists and advanced practice providers, were associated with the highest sacubitril/valsartan use. After multivariable adjustment, the number of advanced practice providers was associated with sacubitril/valsartan use (adjusted odds ratio,1.08; 95% CI, 1.03-1.14). Conclusions Despite current guideline recommendations, adoption of sacubitril/valsartan remains low. Provider and practice characteristics associated with sacubitril/valsartan use were related to general practice size and were not associated with practice characteristics specific for heart failure. Further research is needed to identify strategies for effective quality improvement interventions in chronic heart failure with reduced ejection fraction.

Economic evaluation of guideline implementation in primary care: a systematic review

Purpose

To review the economic evaluation of the guideline implementation in primary care.

Data sources

Medline and Embase.

Study selection

Electronic search was conducted on April 1, 2019, focusing on studies published in the previous ten years in developed countries about guidelines of non-communicable diseases of adult (≥18 years) population, the interventions targeting the primary care provider. Data extraction was performed by two independent researchers using a Microsoft Access based form.

Results of data synthesis

Among the 1338 studies assessed by title or abstract, 212 qualified for full text reading. From the final 39 clinically eligible studies, 14 reported economic evaluation. Cost consequences analysis, presented in four studies, provided limited information. Cost-benefit analysis was reported in five studies. Patient mediated intervention, and outreach visit applied in two studies showed no saving. Audit resulted significant savings in lipid lowering medication. Audit plus financial intervention was estimated to reduce referrals into secondary care. Analysis of incremental cost-effectiveness ratios was applied in four studies. Educational meeting evaluated in a simulated practice was cost-effective. Educational meeting extended with motivational interview showed no improvement; likewise two studies of multifaceted intervention. Cost-utility analysis of educational meeting supported with other educational materials showed unfavourable outcome.

Conclusion

Only a minor proportion of studies reporting clinical effectiveness of guideline implementation interventions included any type of economic evaluation. Rigorous and standardized cost-effectiveness analysis would be required, supporting decision-making between simple and multifaceted interventions through comparability.

Leadership perspective on the implementation of guidelines on healthcare-associated infections

Background

Leadership is a key component for infection prevention and control and plays an important role in the implementation of guidelines on healthcare-associated infections. A body of literature exists on healthcare workers’ perspectives on implementing these types of guidelines; however, there is a paucity of data on the leadership perspectives on implementation. This study aims to contribute to the evidence base of leadership perspectives.

Objective

To explore the implementation of National Clinical Guidelines pertaining to methicillin-resistant Staphylococcus aureus and Clostridium difficile from the leadership angle.

Setting

Healthcare organisations.

Participants

Clinical and non-clinical leaders.

Design

This research used a mixed-methods approach comprising qualitative individual interviews (n=16) and quantitative surveys (n=51) underpinned by the integrated Promoting Action on Research Implementation in Health Services framework.

Results

Leaders recognise the value and innovation of guidelines to support clinical practice. However, they describe barriers to implementation that prevent the full uptake of guidelines, for example, guidelines may present an ideological approach to care which differs from the contextual reality of clinical practice where resources and time are not always available.

Conclusion

This research highlighted that guidelines are complex interventions in complex organisations, perhaps leadership could help overcome the challenges posed by this complexity. Leadership may allow a systematic approach to all aspects of implementation despite the variety of challenges faced at different stages of implementation and sustainability of uptake of guidelines over time.