Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke

BACKGROUND

In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit.

MAIN TEXT

Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement.

CONCLUSIONS

The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals

BACKGROUND

Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways.

OBJECTIVE

To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke.

METHODS

A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values.

RESULTS

From the individual perspective, pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre » Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital » Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective.

CONCLUSION

Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.

Is it possible to make 'living' guidelines? An evaluation of the Australian Living Stroke Guidelines

BACKGROUND

Keeping best practice guidelines up-to-date with rapidly emerging research evidence is challenging. 'Living guidelines' approaches enable continual incorporation of new research, assisting healthcare professionals to apply the latest evidence to their clinical practice. However, information about how living guidelines are developed, maintained and applied is limited. The Stroke Foundation in Australia was one of the first organisations to apply living guideline development methods for their Living Stroke Guidelines (LSGs), presenting a unique opportunity to evaluate the process and impact of this novel approach.

METHODS

A mixed-methods study was conducted to understand the experience of LSGs developers and end-users. We used thematic analysis of one-on-one semi-structured interview and online survey data to determine the feasibility, acceptability, and facilitators and barriers of the LSGs. Website analytics data were also reviewed to understand usage.

RESULTS

Overall, the living guidelines approach was both feasible and acceptable to developers and users. Facilitators to use included collaboration with multidisciplinary clinicians and stroke survivors or carers. Increased workload for developers, workload unpredictability, and limited information sharing, and interoperability of technological platforms were identified as barriers. Users indicated increased trust in the LSGs (69%), likelihood of following the LSGs (66%), and frequency of access (58%), compared with previous static versions. Web analytics data showed individual access by 16,517 users in 2016 rising to 53,154 users in 2020, a threefold increase. There was also a fourfold increase in unique LSG pageviews from 2016 to 2020.

CONCLUSIONS

This study, the first evaluation of living guidelines, demonstrates that this approach to stroke guideline development is feasible and acceptable, that these approaches may add value to developers and users, and may increase guideline use. Future evaluations should be embedded along with guideline implementation to capture data prospectively.

Barriers to and facilitators of living guidelines use in low-income and middle-income countries: a scoping review

INTRODUCTION

Living guidelines provide reliable, ongoing evidence surveillance and regularly updated recommendations for healthcare decision-making. As a relatively new concept, most of the initial application of living approaches has been undertaken in high-income countries. However, in this scoping review, we looked at what is currently known about how living guidelines were developed, used and applied in low-income and middle-income countries.

METHODS

Searches for published literature were conducted in Medline, Global Health, Cochrane Library and Embase. Grey literature was identified using Google Scholar and the WHO website. In addition, the reference lists of included studies were checked for missing studies. Studies were included if they described or reflected on the development, application or utility of living guideline approaches for low-income and middle-income countries.

RESULTS

After a full-text review, 21 studies were included in the review, reporting on the development and application of living recommendations in low-income and middle-income countries. Most studies reported living guideline activities conducted by the WHO (15, 71.4%), followed by China (4, 19%), Chile (1, 4.8%) and Lebanon (1, 4.8%). All studies based on WHO reports relate to living COVID-19 management guidelines.

CONCLUSIONS

Most of the studies in this review were WHO-reported studies focusing solely on COVID-19 disease treatment living guidelines. However, there was no clear explanation of how living guidelines were used nor information on the prospects for and obstacles to the implementation of living guidelines in low-income and middle-income countries.

Functional independence measured in the acute phase of stroke predicts both generic and specific health-related quality of life: a 3-month prospective study in a middle-income country

PURPOSE

To identify acute predictors of both generic and specific health-related quality of life (HRQoL) 3 months after stroke in individuals from a middle-income country.

MATERIALS AND METHODS

A 3-month prospective study with individuals who had suffered their first stroke, without previous disability, discharged from a stroke unit. The dependent outcomes, assessed 3 months after stroke, were generic and specific HRQoL (SF-36 and SSQOL total scores, respectively). The predictors assessed in the stroke unit were age, sex, education level, duration of hospital stay, current living arrangement, stroke severity (National Institutes of Health Stroke Scale-NIHSS), functional independence (Modified Barthel Index-MBI), motor impairment (Fugl-Meyer Assessment), and lower- and upper-limb residual muscle strength deficits. Linear multiple regression analyses were employed to identify predictors of both generic (model-1) and specific (model-2) HRQoL (α = 5%).

RESULTS

One hundred twenty-six individuals were assessed at 3-month post-stroke (61.3 ± 13.6 years). Regression analysis showed that functional independence was the best predictor of both generic (R2 = 21%; F = 34.82; p < 0.001) and specific (R2 = 29%; F = 51.71; p < 0.001) HRQoL at 3-month post-stroke.

CONCLUSION

Both generic and specific HRQoL at 3-month post-stroke can be predicted by functional independence assessed in the acute phase with the MBI.

Stroke Inpatient Rehabilitation Environments: Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping

BACKGROUND

Stroke inpatient rehabilitation is a complex process involving stroke survivors, staff, and family utilizing a common space for a shared purpose: to optimize recovery. This complex pathway is rarely fully described. Stroke care is ideally guided by Clinical Practice Guidelines, and the rehabilitation built environment should serve to optimize care delivery, patient and staff experience. We aimed to articulate the inpatient stroke rehabilitation process of care in a series of process maps, and to understand the degree to which current stroke clinical and building construction (ie, design) guidelines align to support inpatient stroke rehabilitation.

METHODS

We used the Value-Focused Process Engineering methodology to create maps describing the events and activities that typically occur in the current stroke inpatient rehabilitation service model. These maps were completed through individual and group session consultations with stroke survivors, architects, policy makers, and clinical experts. We then determined which sections of the Australian Stroke Rehabilitation Guidelines and the Australasian Health Facility Design Guidelines could be aligned and applied to the process maps.

RESULTS

We present a summary process map for stroke inpatient rehabilitation, alongside detailed process maps for 4 different phases of rehabilitation (admission, a normal weekday, a weekend day, and discharge) using Value-Focused Process Engineering notation. The integration of design and clinical guidelines with care pathway maps revealed where guidelines lack detail to be readily linked to current stroke inpatient care practice, providing an opportunity to design stroke inpatient rehabilitation spaces based on the activities occurring within them.

CONCLUSIONS

Our findings highlight gaps where clinical and design experts should work together to use guidelines to their full potential; and to improve the process of planning for future stroke rehabilitation units.

From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal

BACKGROUND

The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked.

OBJECTIVES

This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient.

METHODS

The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings.

RESULTS

A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040).

CONCLUSION

A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

BACKGROUND

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

AIMS

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

SUMMARY OF REVIEW

Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

CONCLUSION

The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Methods for living guidelines: early guidance based on practical experience. Paper 2: consumer engagement in living guidelines

OBJECTIVES

To describe and reflect on the consumer engagement approaches used in five living guidelines from the perspectives of consumers (i.e., patients, carers, the public, and their representatives) and guideline developers.

STUDY DESIGN AND SETTING

In a descriptive report, we used a template to capture engagement approaches and the experiences of consumers and guideline developers in living guidelines in Australia and the United Kingdom. Responses were summarized using descriptive synthesis.

RESULTS

One guideline used a Consumer Panel, three included two to three consumers in the guideline development group, and one did both. Much of our experience was common to all guidelines (e.g., consumers felt welcomed but that their role initially lacked clarity). We identified six challenges and opportunities specific to living guidelines: managing the flow of work; managing engagement in online environments; managing membership of the panel; facilitating more flexibility, variety and depth in engagement; recruiting for specific skills-although these can be built over time; developing living processes to improve; and adapting consumer engagement together.

CONCLUSION

Consumer engagement in living guidelines should follow established principles of consumer engagement in guidelines. Conceiving the engagement as living, underpinned by a living process evaluation, allows the approach to be developed with consumers over time.

Care for adults with COVID ‐19: living guidelines from the National COVID ‐19 Clinical Evidence Taskforce

Introduction

The Australian National COVID‐19 Clinical Evidence Taskforce was established in March 2020 to maintain up‐to‐date recommendations for the treatment of people with coronavirus disease 2019 (COVID‐19). The original guideline (April 2020) has been continuously updated and expanded from nine to 176 recommendations, facilitated by the rapid identification, appraisal, and analysis of clinical trial findings and subsequent review by expert panels.

Main recommendations

In this article, we describe the recommendations for treating non‐pregnant adults with COVID‐19, as current on 1 August 2022 (version 61.0). The Taskforce has made specific recommendations for adults with severe/critical or mild disease, including definitions of disease severity, recommendations for therapy, COVID‐19 prophylaxis, respiratory support, and supportive care.

Changes in management as a result of the guideline

The Taskforce currently recommends eight drug treatments for people with COVID‐19 who do not require supplemental oxygen (inhaled corticosteroids, casirivimab/imdevimab, molnupiravir, nirmatrelvir/ritonavir, regdanvimab, remdesivir, sotrovimab, tixagevimab/cilgavimab) and six for those who require supplemental oxygen (systemic corticosteroids, remdesivir, tocilizumab, sarilumab, baricitinib, casirivimab/imdevimab). Based on evidence of their achieving no or only limited benefit, ten drug treatments or treatment combinations are not recommended; an additional 42 drug treatments should only be used in the context of randomised trials. Additional recommendations include support for the use of continuous positive airway pressure, prone positioning, and endotracheal intubation in patients whose condition is deteriorating, and prophylactic anticoagulation for preventing venous thromboembolism. The latest updates and full recommendations are available at www.covid19evidence.net.au.

Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

Objective

Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline "evidence-based rehabilitation of mobility after stroke (ReMoS)," the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations.

Materials and Methods

This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed.

Conclusion

This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.

The Australian living guidelines for the clinical care of people with COVID-19: What worked, what didn't and why, a mixed methods process evaluation

Introduction

The Australian National COVID-19 Clinical Evidence Taskforce is producing living, evidence-based, national guidelines for treatment of people with COVID-19 which are updated each week. To continually improve the process and outputs of the Taskforce, and inform future living guideline development, we undertook a concurrent process evaluation examining Taskforce activities and experience of team members and stakeholders during the first 5 months of the project.

Methods

The mixed-methods process evaluation consisted of activity and progress audits, an online survey of all Taskforce participants; and semi-structured interviews with key contributors. Data were collected through five, prospective 4-weekly timepoints (beginning first week of May 2020) and three, fortnightly retrospective timepoints (March 23, April 6 and 20). We collected and analysed quantitative and qualitative data.

Results

An updated version of the guidelines was successfully published every week during the process evaluation. The Taskforce formed in March 2020, with a nominal start date of March 23. The first version of the guideline was published two weeks later and included 10 recommendations. By August 24, in the final round of the process evaluation, the team of 11 staff, working with seven guideline panels and over 200 health decision-makers, had developed 66 recommendations addressing 58 topics. The Taskforce website had received over 200,000 page views. Satisfaction with the work of the Taskforce remained very high (>90% extremely or somewhat satisfied) throughout. Several key strengths, challenges and methods questions for the work of the Taskforce were identified.

Conclusions

In just over 5 months of activity, the National COVID-19 Clinical Evidence Taskforce published 20 weekly updates to the evidence-based national treatment guidelines for COVID-19. This process evaluation identified several factors that enabled this achievement (e.g. an extant skill base in evidence review and convening), along with challenges that needed to be overcome (e.g. managing workloads, structure and governance) and methods questions (pace of updating, and thresholds for inclusion of evidence) which may be useful considerations for other living guidelines projects. An impact evaluation is also being conducted separately to examine awareness, acceptance and use of the guidelines.

Telehealth for rehabilitation and recovery after stroke: State of the evidence and future directions

AIMS

The aim of this rapid review and opinion paper is to present the state of the current evidence and present future directions for telehealth research and clinical service delivery for stroke rehabilitation.

METHODS

We conducted a rapid review of published trials in the field. We searched Medline using key terms related to stroke rehabilitation and telehealth or virtual care. We also searched clinical trial registers to identify key ongoing trials.

RESULTS

The evidence for telehealth to deliver stroke rehabilitation interventions is not strong and is predominantly based on small trials prone to Type 2 error. To move the field forward, we need to progress to trials of implementation that include measures of adoption and reach, as well as effectiveness. We also need to understand which outcome measures can be reliably measured remotely, and/or develop new ones. We present tools to assist with the deployment of telehealth for rehabilitation after stroke.

CONCLUSION

The current, and likely long-term, pandemic means that we cannot wait for stronger evidence before implementing telehealth. As a research and clinical community, we owe it to people living with stroke internationally to investigate the best possible telehealth solutions for providing the highest quality rehabilitation.

Care of older people and people requiring palliative care with COVID-19: guidance from the Australian National COVID-19 Clinical Evidence Taskforce

Introduction

Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID‐19) experience higher rates of critical illness. There are also people who become critically ill with COVID‐19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID‐19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia.

Main recommendations

The panel was tasked with developing two clinical flow charts for the management of people with COVID‐19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID‐19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease‐directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID‐19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care.

Changes in management as result of the guideline

The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID‐19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

Awareness, value and use of the Australian living guidelines for the clinical care of people with COVID-19: an impact evaluation

BACKGROUND AND OBJECTIVE

The Australian National COVID-19 Clinical Evidence Taskforce is developing living, evidence-based, national guidelines for treatment of people with COVID-19. These living guidelines are updated each week. We undertook an impact evaluation to understand the extent to which health professionals providing treatment to people with COVID 19 were aware of, valued and used the guidelines, and the factors that enabled or hampered this.

METHODS

A mixed methods approach was used for the evaluation. Surveys were conducted to collect both quantitative and qualitative data and were supplemented with qualitative interviews. Australian healthcare practitioners potentially providing care to individuals with suspected or confirmed COVID-19 were invited to participate. Data were collected on guideline awareness, relevance, ease of use, trustworthiness, value, importance of updating, use, and strengths and opportunities for improvement.

RESULTS

A total of 287 people completed the surveys and 10 interviews were conducted during November 2020. Awareness of the work of the Taskforce was high and the vast majority of respondents reported that the guidelines were very or extremely relevant, easy to use, trustworthy and valuable. More than 50% of respondents had used the guidelines to support their own clinical decision-making; and 30% were aware of other examples of the guidelines being used. Qualitative data revealed that amongst an overwhelming morass of evidence and opinions during the COVID-19 pandemic, the guidelines have been a reliable, united source of evidence-based advice; participants felt the guidelines built confidence and provided reassurance in clinical decision-making. Opportunities to improve awareness and accessibility to the guidelines were also explored.

CONCLUSIONS

As of June 2021, the guidelines have been published and updated more than 40 times, include more than 140 recommendations and are being used to inform clinical decisions. The findings of this impact evaluation will be used to improve processes and outputs of the Taskforce and guidelines project, and to inform future living guideline projects.

Feasibility of national living guideline methods: the Australian Stroke Guidelines

OBJECTIVE

Maintaining clinical guideline currency has been one challenge to traditional guideline development. This paper describes the methods used to maintain a large national guideline for stroke management.

STUDY DESIGN AND SETTING

The Australian Stroke Clinical Guidelines are developed to meet Australian National Health and Medical Research Council (NHMRC) standards. Monthly surveillance is conducted for new systematic reviews and randomised controlled studies. Included studies undergo data extraction followed by preparation of updated evidence-to-decision frameworks which are used to inform updates, or development of new recommendations. Small writing groups made up of clinical experts and those with lived experience review and agree on changes, which are finally reviewed by a multidisciplinary Guidelines Steering Group. Draft changes are developed and published using the online MAGICapp platform, with dissemination and promotion via traditional methods as well as social media.

RESULTS

Each month approximately 350 abstracts are considered, covering 96 clinical topics and taking on average 16 hours to review. There have been four major guideline updates covering 34 new and updated recommendations.

CONCLUSION

It is feasible to use 'living' methods to maintain the Australian Clinical Guidelines for Stroke Management. Further work is now needed to understand the impact of living guidelines.

Examining user perspective of an online learning resource for physiotherapists: A mixed methods study of the TRAIN program

BACKGROUND

Implementing task specific training is a commonly reported challenge for less experienced therapists. A potential method to improve the ability of recent graduate and student therapists is to upskill regarding task specific training via an online education resource.

PURPOSE

To evaluate the use and acceptability of the TRAIN program as an online learning resource for physiotherapists.

METHODS

Data from Google Analytics was sourced to determine use of the program and details about the users. Users of the TRAIN program were also invited to complete two surveys; prior to beginning and upon completion of the program. The surveys collected information about the demographics of the users, perceptions of usefulness of the online resource and overall sentiment.

RESULTS

Almost 6000 new users interacted with the TRAIN modules during the 15-months study period. The surveys indicated a high level of usability (mean score 9/10, SD 1.5) and clinical utility (mean score 8.8/10, SD 1.6) of the TRAIN program. Perceived knowledge and user confidence in implementing task-specific training was higher for those users completing the post compared to those completing the pre-module survey (knowledge 1.9 and confidence 1.7 out of 10 points higher). Recurring comments in the open-ended feedback pertained to the usefulness, clarity, and ease of use of the TRAIN program.

DISCUSSION AND CONCLUSION

This study provides preliminary evidence supporting the use and acceptability of the TRAIN program as an online learning resource for physiotherapists. This further contributes to the growing body of literature indicating online learning is generally a well-received teaching tool for physiotherapists.

Clinical care of pregnant and postpartum women with COVID-19: Living recommendations from the National COVID-19 Clinical Evidence Taskforce

To date, 18 living recommendations for the clinical care of pregnant and postpartum women with COVID-19 have been issued by the National COVID-19 Clinical Evidence Taskforce. This includes recommendations on mode of birth, delayed umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, antenatal corticosteroids, angiotensin-converting enzyme inhibitors, disease-modifying treatments (including dexamethasone, remdesivir and hydroxychloroquine), venous thromboembolism prophylaxis and advanced respiratory support interventions (prone positioning and extracorporeal membrane oxygenation). Through continuous evidence surveillance, these living recommendations are updated in near real-time to ensure clinicians in Australia have reliable, evidence-based guidelines for clinical decision-making. Please visit https://covid19evidence.net.au/ for the latest recommendation updates.

Weekly updates of national living evidence-based guidelines: methods for the Australian living guidelines for care of people with COVID-19

Background and Objectives

The Australian National COVID-19 Clinical Evidence Taskforce is a consortium of 31 Australian health professional organisations developing living, evidence-based guidelines for care of people with COVID-19, which are updated weekly. This article describes the methods used to develop and maintain the guidelines.

Methods

The guidelines use the GRADE methods and are designed to meet Australian NHMRC standards. Each week, new evidence is reviewed, current recommendations are revised, and new recommendations made. These are published in MAGIC and disseminated through traditional and social media. Relevant new questions to be addressed are continually sought from stakeholders and practitioners. For prioritized questions, the evidence is actively monitored and updated. Evidence surveillance combines horizon scans and targeted searches. An evidence team appraises and synthesizes evidence and prepares evidence-to-decision frameworks to inform development of recommendations. A guidelines leadership group oversees the development of recommendations by multidisciplinary guidelines panels and is advised by a consumer panel.

Results

: The Taskforce formed in March 2020, and the first recommendations were published 2 weeks later. The guidelines have been revised and republished on a weekly basis for 24 weeks, and as of October 2020, contain over 90 treatment recommendations, suggesting that living methods are feasible in this context.

Conclusions

The Australian guidelines for care of people with COVID-19 provide an example of the feasibility of living guidelines and an opportunity to test and improve living evidence methods.

Clinical guidelines for caring for women with COVID-19 during pregnancy, childbirth and the immediate postpartum period

Background

The spread of the novel coronavirus (COVID-19) was declared a pandemic by the World Health Organization on 11th March 2020. Since then there has been a rapid rise in development of maternal and perinatal health guidelines related to COVID-19. The aim of this project was to develop a database of Australian and international recommendations relating to antenatal, intrapartum and postpartum care of women during the COVID-19 pandemic, in order to identify inconsistencies in clinical guidance.

Methods

We conducted weekly web searches from 30th March to 15th May 2020 to identify recommendations pertaining to the care of women during pregnancy, labour and postpartum period from national or international professional societies, specialist colleges, Ministries of Health, Australian state and territory governments, and international guideline development organisations. Individual recommendations were extracted and classified according to intervention type, time period, and patient population. Findings were reported using descriptive analysis, with areas of consensus and non-consensus identified.

Results

We identified 81 guidelines from 48 different organisations. Generally, there was high consensus across guidelines for specific interventions. However, variable guidance was identified on the use of nitrous oxide during labour, administration of antenatal corticosteroids, neonatal isolation after birth, labour and birth companions, and the use of disease modifying agents for treating COVID-19.

Conclusion

Discrepancies between different guideline development organisations creates challenges for maternity care clinicians during the COVID-19 pandemic. Collating recommendations and keeping up-to-date with the latest guidance can help clinicians provide the best possible care to pregnant women and their babies.

Towards a new model for producing evidence-based guidelines: a qualitative study of current approaches and opportunities for innovation among Australian guideline developers

Background: Many organisations in Australia undertake systematic reviews to inform development of evidence-based guidelines or would like to do so. However, the substantial resources required to produce systematic reviews limit the feasibility of evidence-based approaches to guideline development. We are working with Australian guideline developers to design, build and test systems that make creating evidence-based guidelines easier and more efficient. Methods: To understand the evidence needs of guideline developers and to inform the development of potential tools and services, we conducted 16 semi-structured interviews with Australian guideline developers. Developers were involved in different types of guidelines, represented both new and established guideline groups, and had access to widely different levels of resources. Results: All guideline developers recognised the importance of having access to timely evidence to support their processes, but were frequently overwhelmed by the scale of this task. Groups developing new guidelines often underestimated the time, expertise and work involved in completing searching and screening. Many were grappling with the challenge of updating and were keen to explore alternatives to the blanket updating of the full guideline. Horizon-scanning and evidence signalling were seen as providing more pragmatic approaches to updating, although some were wary of challenges posed by receiving evidence on a too-frequent basis. Respondents were aware that new technologies, such as machine learning, offered potentially large time and resource savings. Conclusions: As well as the constant challenge of managing financial constraints, Australian guideline developers seeking to develop clinical guidelines face several critical challenges. These include acquiring appropriate methodological expertise, investing in information technology, coping with the proliferation of research output, feasible publication and dissemination options, and keeping guidance up to date.