Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review

Axial spondyloarthritis guidelines - aiming for maximum impact

PURPOSE OF REVIEW

This review discusses international clinical practice guidelines (CPGs) for axial spondyloarthritis (axSpA) focusing on methodology, guideline quality, and implementation.

RECENT FINDINGS

The Assessment of SpondyloArthritis International Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) and Pan-American League of Associations for Rheumatology (PANLAR) recently published axSpA CPGs and updates of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Asia-Pacific League of Associations for Rheumatology (APLAR) CPGs are expected. GRADE has emerged as the dominant framework for CPG development and has been used by three of the four international axSpA guidelines. Notable differences exist among these guidelines in the way that the recommendations are presented. Two of the four acknowledge the need for implementation strategies, but little detail about this is provided. The few studies that have evaluated the implementation of axSpA CPGs have identified poor adherence to recommendations on physical therapy/exercise and disease activity monitoring. Implementation science has identified many barriers and facilitators affecting guideline uptake, including those related to healthcare professionals and to the guidelines themselves. Creation of a tailored implementation plan simultaneously with the CPG is recommended.

SUMMARY

While methodological rigor in the creation of evidence-based recommendations is the focus of CPG development, recommendations must be presented in a user-friendly format that makes them easy to apply. 'Living guidelines' could facilitate keeping content up to date. Implementation is critical for the success of a CPG and should be emphasized in future axSpA guideline updates. Further research is needed to better understand the factors impacting the successful implementation of axSpA CPGs.

Smoking Cessation Support in Social and Community Service Organizations: Potential Activities, Barriers, and Facilitators

INTRODUCTION

Social and Community Service Organizations (SCSOs) are a potential setting to reach and support people with a low socioeconomic position who smoke, yet smoking cessation is not widely supported by SCSO professionals.

AIMS AND METHODS

This study aims to identify SCSO professionals' (1) potential activities to support smoking cessation and (2) barriers and facilitators in undertaking these activities. Between July and November 2022, semi-structured interviews were conducted with 21 professionals recruited through SCSOs in Amsterdam North, including participation workers, welfare workers, parent and child counselors, budget coach, debt counselor, welfare work, community sports, and community center coordinators. Data were analyzed using a thematic approach.

RESULTS

Eight activities were identified that could support the client either directly (ie, recognizing smoking clients, discussing smoking and smoking cessation, referring clients, providing smoking cessation counseling, offering help around services) or indirectly (ie, collaboration with relevant network partners, implementing smoke-free environments, enhancing professional skills). Various barriers and facilitators were identified related to the (1) client and their environment (ie, clients' readiness and social environment), (2) interaction between professional and client (ie, topic sensitivity), (3) professional (ie, professional is non-smoker, knowledge, and self-efficacy), (4) professionals' work environment (ie, necessity, responsibility, priority, and time), and (5) smoking cessation services (ie, availability of appropriate services and referral process).

CONCLUSIONS

There is potential for SCSO professionals to support smoking cessation, but several barriers hinder their efforts. To address these barriers, it is essential to take into account the factors that SCSO professionals believe facilitate the provision of smoking cessation support.

IMPLICATIONS

This study provides insight into how the potential of SCSOs in Amsterdam North to support smoking cessation efforts among people with a low socioeconomic position can be harnessed. Barriers were found at multiple levels (client, professional, client-professional interaction, and organizational) and these findings imply that stakeholders across these levels will need to prioritize smoking cessation to facilitate and stimulate SCSO professionals in supporting smoking cessation. A concrete action would be to offer SCSO professionals additional training in conversational skills to discuss smoking. As a prerequisite, easily accessible and suitable smoking cessation services should be available in the neighborhood.

Comparative global analysis of stroke rehabilitation recommendations across income levels

OBJECTIVE

Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC).

STUDY DESIGN AND SETTING

We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC.

RESULTS

The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations.

CONCLUSION

There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

How consistent are the key recommendations, and what is the quality of guidelines and expert consensus regarding paediatric cow's milk protein allergy?

The objective of this study was to assess the quality and consistency of recommendations in clinical practice guidelines (CPGs) and expert consensus on paediatric cow's milk protein allergy (CMPA) to serve as a foundation for future revisions and enhancements of clinical guidelines and consensus documents. We conducted a comprehensive literature search across several databases, including the Chinese Biomedical Literature Database (CBM), PubMed, Embase, Web of Science, UpToDate, ClinicalKey, DynaMed Plus and BMJ Best Practice. We spanned the search period from the inception of each database through October 1, 2023. We integrated subject headings (MeSH/Emtree) and keywords into the search strategy, used the search methodologies of existing literature and developed it in collaboration with a librarian. Two trained researchers independently conducted the literature screening and data extraction. We evaluated methodological quality and recommendations by using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and AGREE-Recommendations for Excellence (AGREE-REX) tools. Moreover, we compared and summarized key recommendations from high-quality CPGs. Our study included 27 CPGs and expert consensus documents on CMPA. Only four CPGs (14.8%) achieved a high-quality AGREE II rating. The four high-quality CPGs consistently provided recommendations for CMPA. The highest scoring domains for AGREE II were 'scope and purpose' (77 ± 12%) and 'clarity of presentation' (75 ± 22%). The lowest scoring domains were 'stakeholder involvement' (49 ± 21%), 'rigor of development' (34 ± 20%) and 'applicability' (12 ± 20%). Evaluation with AGREE-REX generally demonstrated low scores across its domains.   Conclusion: Recommendations within high-quality CPGs for the paediatric CMPA showed fundamental consistency. Nevertheless, the methodology and recommendation content of CPGs and the expert consensus exhibited low quality, thus indicating a substantial scope for enhancement. Guideline developers should rigorously follow the AGREE II and AGREE-REX standards in creating CPGs or expert consensuses to guarantee their clinical efficacy in managing paediatric CMPA. What is Known: • The quality of clinical practice guidelines and expert consensus on paediatric cow's milk protein allergy (CMPA) remains uncertain. • There is a lack of clarity regarding the consistency of crucial recommendations for CMPA management. What is New: • Improving the methodological quality of guidelines and consensus on CMPA requires greater emphasis on stakeholder engagement, rigorous development processes, and practical applicability. • The recommendations from four high-quality guidelines align. However, addressing clinical applicability, integrating values and preferences, and ensuring actionable implementation are critical to improving the quality of all guidelines.

Clinical inertia in thyrotropin suppressive therapy for low-risk differentiated thyroid cancer: A real-world experience at an endocrine center in Bangkok

The management of low-risk differentiated thyroid cancer (DTC) has evolved over time toward treatment de-escalation. However, overtreatment with supraphysiological dose of levothyroxine (LT4) continues to be observed despite current clinical guideline. This study aimed to assess the actual thyrotropin suppressive therapy for low-risk DTC patients at an endocrine center in Bangkok. This retrospective study included patients with low-risk DTC who were regularly follow-up for at least 18 months at Theptarin Hospital between 2016 and 2022. The serum thyroid stimulating hormone (TSH) levels were stratified as TSH < 0.1 mIU/L; TSH 0.1 to 0.5 mIU/L; TSH 0.5 to 2.0 mIU/L; and TSH > 2.0 mIU/L. The initial risk stratification (IRS) and dynamic risk stratification were determined at 12 months of follow-up after completing the initial treatment and at the last visit. The clinical factors associated with overtreatment with LT4 were analyzed. A total of 102 patients (83.3% female, age at diagnosis 41.8 ± 13.6 years, mean tumor size 1.6 ± 1.0 cm) were evaluated with a mean follow-up of 5.9 years. The IRS classified 92.2% of patients after the initial treatment and 93.1% of patients at the last follow-up visit into the excellent response category. The mean LT4 daily dosage at the last follow-up was 121.3 ± 44.8 µg/day. Serum TSH levels were in an appropriate target range according to IRS in only 8.8% (9/102) of the patients and then improved to 19.6% (20/102) at the last follow-up visit. Further analysis showed that treating physicians with ≥10 years of practice was associated with severe TSH suppression therapy (TSH < 0.1 mIU/L). Despite the current clinical guideline recommendations and scientific evidences, less than one-fifth of low-risk DTC patients achieved the appropriate serum TSH target. While the proportion of an optimum LT4 suppressive had improved during the study period, further efforts are needed to overcome this clinical inertia.

Axial Spondyloarthritis Treatment Recommendations and Disease Activity Monitoring in Clinical Practice: Results of an Online Survey

OBJECTIVE

Clinical practice guidelines are not always followed consistently. To better understand potential barriers to the implementation of treatment recommendations in axial spondyloarthritis and ankylosing spondylitis (axSpA/AS), an online survey was conducted.

METHODS

Email invitations were sent to US rheumatology care providers in January 2023. The questionnaire included 20 questions, with an estimated completion time of 5-7 minutes.

RESULTS

One hundred four of 441 (24%) invitees participated, including 80/104 (77%) board-certified rheumatologists and 20/104 (19%) fellows. Survey participants identified UpToDate (85%), treatment guidelines (74%), and colleagues (54%) as relevant sources of knowledge for managing axSpA/AS. Of the participants, 64% and 53% considered themselves to be at least moderately familiar with the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Assessment of Spondyloarthritis international Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) treatment recommendations for axSpA/AS, respectively. Whereas 69% of participants agreed or strongly agreed that disease activity scores are useful for making treatment decisions in axSpA/AS, only 37% measure patient-reported outcomes (PROs) frequently (≥ 50% of clinic visits) while 82% do so for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). PROs are typically recorded during clinic encounters (65%) and CRP/ESR are obtained after the visit (86%). Of the participants, 57% and 47% considered the Bath Ankylosing Spondylitis Disease Activity Index and Ankylosing Spondylitis Disease Activity Score to be at least moderately useful for measuring disease activity in axSpA/AS, respectively; 41% and 37% thought the same about the ASAS 20% improvement criteria and Clinical Disease Activity Index, respectively.

CONCLUSION

Treatment guidelines are an important resource for rheumatologists who manage patients with axSpA/AS. Although there is general agreement that disease activity monitoring is important, the implementation of the respective recommendations is lacking. Reasons may include lack of familiarity and an underdeveloped infrastructure to efficiently collect PROs.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure

BACKGROUND

The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.

METHODS

General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.

RESULTS

Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.

CONCLUSIONS

Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

Translating evidence into practice in primary care management of adolescents and women with polycystic ovary syndrome: a mixed-methods study

BACKGROUND

The international guideline on polycystic ovary syndrome (PCOS) provides evidence-based recommendations on the management of PCOS. Guideline implementation tools (GItools) were developed for general practitioner (GP) use to aid rapid translation of guidelines into practice. This mixed-methods study aimed to evaluate barriers and enablers of the uptake of PCOS GItools in general practice.

DESIGN AND SETTING

A cross-sectional survey was distributed through professional networks and social media to GPs and GPs in training in Australia. Survey respondents were invited to contribute to semi-structured interviews. Interviews were audio-recorded and transcribed verbatim. Qualitative data were thematically analysed and mapped deductively to the Theoretical Domains Framework and Capability, Opportunity, Motivation and Behaviour model.

RESULTS

The study engaged 146 GPs through surveys, supplemented by interviews with 14 participants. A key enabler to capability was reflective practice. Barriers relating to opportunity included limited awareness and difficulty locating and using GItools due to length and lack of integration into practice software, while enablers included ensuring recommendations were relevant to GP scope of practice. Enablers relevant to motivation included co-use with patients, and evidence of improved outcomes with the use of GItools.

DISCUSSION

This study highlights inherent barriers within the Australian healthcare system that hinder GPs from integrating evidence for PCOS. Findings will underpin behaviour change interventions to assist GPs in effectively utilising guidelines in clinical practice, therefore minimising variations in care. While our findings will have a direct influence on guideline translation initiatives, changes at organisational and policy levels are also needed to address identified barriers.

Exploring Early, Middle, and Late Loss in Basic Activities of Daily Living among Nursing Home Residents: A Multicenter Observational Study

Nursing home (NH) residents commonly face limitations in basic activities of daily living (BADLs), following a hierarchical decline. Understanding this hierarchy is crucial for personalized care. This study explores factors associated with early, middle, and late loss in BADLs among NH residents. A multicenter cross-sectional study was conducted in 30 NHs in Catalonia, Spain. Dependent variables were related to limitations in BADLs: early loss (self-care-related BADLs: personal hygiene, dressing, or bathing), middle loss (mobility-related BADLs: walking or wheelchair handling, toileting, and transferring), and late loss (eating). Independent variables were based on a comprehensive geriatric assessment and institutional factors. Logistic regression was used for the multivariate analyses. The study included 671 older adults. Early loss in BADLs was significantly associated with urinary incontinence, cognitive impairment, and falls. Middle loss in BADLs was linked to fecal incontinence, urinary incontinence, ulcers, and cognitive impairment. Late loss in BADLs was associated with fecal incontinence, the NH not owning a kitchen, neurological disease, cognitive impairment, dysphagia, polypharmacy, and weight loss. These findings highlight the need to address geriatric syndromes, especially cognitive impairment and bladder/bowel incontinence. Monitoring these syndromes could effectively anticipate care dependency. The presence of kitchens in NHs may help to address limitations to eating, allowing for potential personalized meal adaptation.

[The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital]

The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital Abstract: Background: With a prevalence of 12-64%, delirium is a common complication in acute care, associated with negative outcomes such as increased mortality and prolonged length of stay. Many hospitals have guidelines to improve the delirium management. The Delirium Observation Screening Scale (DOS) Score is collected in the study hospital from all patients ≥ 70 years at each shift for at least 3 days. Delirium is diagnosed by a physician and coded according to ICD-10. Purpose: Evaluation of the delirium screening with the DOS according to internal guideline in terms of number of DOS assessments performed, prevalence of delirium (DOS score ≥ 3 points, CD-10 code delirium). Method: This retrospective quantitative single-centre longitudinal study used 2017 and 2018 data of 10046 cases. Statistical analysis methods were used to analyse prevalence of delirium and subgroup comparisons. Results: At least one DOS score was documented in 92% of cases aged ≥ 70-years (n = 5038). DOS implementation varied between 60% in the early, 49% in the late and 38% in the night shift. The prevalence of delirium was 12% according to DOS score ≥ 3 and 4% according to physician diagnosis of a delirium. Cases with a DOS score ≥ 3 were significantly older, more often female, had more comorbidities and were depressed. Conclusions: DOS is performed in most patients when indicated. The DOS implementation frequency varied depending on the shift.

To what extent are guidelines used in spasticity clinics? A qualitative study of facilitators and barriers to spasticity guideline implementation

OBJECTIVE

To determine the common understanding of focal muscle spasticity guidelines amongst clinicians working in spasticity clinics. To examine the facilitators and barriers to their implementation as well as their influence on clinic processes.

DESIGN

A qualitative study based on a phenomenological approach.

SETTING

Online videoconferencing platform.

PARTICIPANTS

Sixteen experienced multi-disciplinary clinicians providing specialised care across 12 spasticity clinics in Victoria, Australia.

INTERVENTION

Observational.

MAIN MEASURES

Two independent reviewers performed line by line coding of transcripts. Reflexive thematic analysis was undertaken with themes/subthemes inductively derived.

RESULTS

Seven key themes emerged. First, knowledge of specific guideline recommendations was low amongst some clinicians. Second, there is a lack of health service resources to support guideline implementation. Third, a limited evidence base for guidelines affected clinicians' willingness to implement the recommendations. Fourth, peer support was highly valued but opportunities to collaborate were limited. Fifth, a large amount of intrinsic motivation and personal time was required from clinicians to successfully implement guideline recommendations. Sixth, the standardisation of clinic processes was one way in which clinicians felt they could better align their clinical practice to guidelines. Lastly, guidelines overall had a moderate influence on spasticity clinic processes.

CONCLUSIONS

Knowledge of recommendations varied but, overall, guidelines had an influence on clinic processes and staff perceptions across the state-wide services. Health service resources, limited evidence for guideline recommendations and time constraints were considered barriers to spasticity guideline implementation. Multi-disciplinary expertise and teamwork, the individual's motivation to change and inter-clinic collaboration were considered to be the facilitators.

A qualitative analysis of algorithm-based decision support usability testing for symptom management across the trajectory of cancer care: one size does not fit all

BACKGROUND

Adults with cancer experience symptoms that change across the disease trajectory. Due to the distress and cost associated with uncontrolled symptoms, improving symptom management is an important component of quality cancer care. Clinical decision support (CDS) is a promising strategy to integrate clinical practice guideline (CPG)-based symptom management recommendations at the point of care.

METHODS

The objectives of this project were to develop and evaluate the usability of two symptom management algorithms (constipation and fatigue) across the trajectory of cancer care in patients with active disease treated in comprehensive or community cancer care settings to surveillance of cancer survivors in primary care practices. A modified ADAPTE process was used to develop algorithms based on national CPGs. Usability testing involved semi-structured interviews with clinicians from varied care settings, including comprehensive and community cancer centers, and primary care. The transcripts were analyzed with MAXQDA using Braun and Clarke's thematic analysis method. A cross tabs analysis was also performed to assess the prevalence of themes and subthemes by cancer care setting.

RESULTS

A total of 17 clinicians (physicians, nurse practitioners, and physician assistants) were interviewed for usability testing. Three main themes emerged: (1) Algorithms as useful, (2) Symptom management differences, and (3) Different target end-users. The cross-tabs analysis demonstrated differences among care trajectories and settings that originated in the Symptom management differences theme. The sub-themes of "Differences between diseases" and "Differences between care trajectories" originated from participants working in a comprehensive cancer center, which tends to be disease-specific locations for patients on active treatment. Meanwhile, participants from primary care identified the sub-theme of "Differences in settings," indicating that symptom management strategies are care setting specific.

CONCLUSIONS

While CDS can help promote evidence-based symptom management, systems providing care recommendations need to be specifically developed to fit patient characteristics and clinical context. Findings suggest that one set of algorithms will not be applicable throughout the entire cancer trajectory. Unique CDS for symptom management will be needed for patients who are cancer survivors being followed in primary care settings.

'It depends': what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of strategies have been developed to support the implementation of research into clinical practice. The objective of this study was to update and extend two previous reviews of systematic reviews of strategies designed to implement research evidence into clinical practice.

METHODS

We developed a comprehensive systematic literature search strategy based on the terms used in the previous reviews to identify studies that looked explicitly at interventions designed to turn research evidence into practice. The search was performed in June 2022 in four electronic databases: Medline, Embase, Cochrane and Epistemonikos. We searched from January 2010 up to June 2022 and applied no language restrictions. Two independent reviewers appraised the quality of included studies using a quality assessment checklist. To reduce the risk of bias, papers were excluded following discussion between all members of the team. Data were synthesised using descriptive and narrative techniques to identify themes and patterns linked to intervention strategies, targeted behaviours, study settings and study outcomes.

RESULTS

We identified 32 reviews conducted between 2010 and 2022. The reviews are mainly of multi-faceted interventions (n = 20) although there are reviews focusing on single strategies (ICT, educational, reminders, local opinion leaders, audit and feedback, social media and toolkits). The majority of reviews report strategies achieving small impacts (normally on processes of care). There is much less evidence that these strategies have shifted patient outcomes. Furthermore, a lot of nuance lies behind these headline findings, and this is increasingly commented upon in the reviews themselves.

DISCUSSION

Combined with the two previous reviews, 86 systematic reviews of strategies to increase the implementation of research into clinical practice have been identified. We need to shift the emphasis away from isolating individual and multi-faceted interventions to better understanding and building more situated, relational and organisational capability to support the use of research in clinical practice. This will involve drawing on a wider range of research perspectives (including social science) in primary studies and diversifying the types of synthesis undertaken to include approaches such as realist synthesis which facilitate exploration of the context in which strategies are employed.

Implementation of the "clinical framework for the delivery of health services" by treating healthcare professionals: perspectives of regulators and insurers

PURPOSE

To understand the current utilisation of the clinical framework for delivery of health services to manage compensable musculoskeletal injuries from the perspectives of insurer case managers and clinical panel members.

MATERIALS AND METHODS

Using a qualitative descriptive approach, 15 semi-structured interviews were conducted with members of key organisations including WorkSafe Victoria and Transport Accident Commission Victoria. All interviews were recorded and transcribed verbatim and analysed using thematic analysis.

RESULTS

Four over-arching themes were identified: (i) current use of the framework and principles is suboptimal leading to several problems including lack of evidence-based treatment by clinicians; (ii) barriers to optimal use of the framework include lack of adequate training of healthcare professionals on the framework principles and financial aspects of the compensation system; (iii) utilisation of the framework could be improved with training from peak associations, insurers, and regulating bodies; and (iv) optimal use of the framework will result in better health and work outcomes.

CONCLUSIONS

The current use of the framework and its principles is suboptimal but can be improved by addressing the identified barriers.IMPLICATIONS FOR REHABILITATIONRehabilitation of compensable musculoskeletal injuries is often complex.Implementing the "Clinical Framework for Delivery of Health Services" can lead to provision of time and cost effective, evidence-based rehabilitation for compensable injuries, ultimately improving patient outcomes.Clinicians can enhance the implementation of the framework principles by integrating evidence-based practice and recommendations from clinical practice guidelines in treatment of compensable musculoskeletal injuries.Implementation of the framework principles may be enhanced by reviewing the compensation funding model to allow the healthcare practitioners adequate time and remuneration to adopt the framework principles when treating persons with compensable injuries.

Feasibility of a selective targeted strategy of HIV testing in emergency departments: a before-after study

BACKGROUND AND IMPORTANCE

The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic.

OBJECTIVE

To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis.

DESIGN

This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios.

SETTINGS AND PARTICIPANTS

Patients attended 34 Spanish EDs.

INTERVENTION OR EXPOSURE

The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results.

OUTCOME MEASURES AND ANALYSIS

The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI).

MAIN RESULTS

HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests.

CONCLUSION

Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses.

The Outcomes, Barriers, and Facilitators of Implementing Clinical Practice Guidelines in Iran: A Comprehensive Review

Background

Clinical practice guideline (CPGs) are highly valuable in enhancing healthcare efficiency as they lead to the selection of the best medical methods and reduction of their costs. Nevertheless, implementing CPGs in practice can be quite challenging, as they require alterations at individual, organizational, and health system levels. Therefore, we aimed to identify the outcomes, barriers, and facilitators associated with CPG implementation.

Methods

We conducted an extensive search using Web of Science, PubMed, Scopus, Embase, and various non-English databases to gather quantitative, qualitative, and review studies on the implementation of CPGs from Jan 1, 1990, to Dec 26, 2022. Our analysis focused on the outcomes, barriers, and facilitators of CPG implementation, which categorized into four groups: policy-making, health system and hospitals, professional experts, and clinical guidelines.

Results

After conducting a thorough review of 37 studies, the most significant outcomes were found to be reduced costs and enhanced quality of care. However, certain challenges, such as inadequate support, insufficient education, high work pressure, tight schedules, and a lack of unified and clear guidelines, hindered these improvements. To overcome these barriers, it is essential to prioritize effective leadership, improve work conditions, allocate necessary resources, create a structured framework for the guidelines, and simplify their content to fit the clinical circumstances.

Conclusion

It is crucial to identify the outcomes and barriers associated with implementing CPGs to enhance professional performance, elevate the quality of care, and foster patient satisfaction. Developing effective strategies hinges on this awareness.

Children with autism spectrum disorder in high technology medicine environments; a qualitative systematic review of parental perspectives

BACKGROUND

Children with autism spectrum disorders are frequent visitors to high technology environments, and their needs may differ from those of their typically developed peers. Procedures in high technology environments can constitute a challenge for these children and their parents since the environment presents many challenges relevant to the child's impairments. This systematic review aimed to explore the experiences of children with autism spectrum disorders and their parents during procedures in a high technology environment.

METHODS

The following sources were searched for this systematic review: Cochrane CENTRAL Trials, CINAHL, Dentistry and Oral Sciences Source, MEDLINE, PsycINFO, Scopus, and Web of Science Core Collection. The search terms included variants of the following concepts: (1) children with autism spectrum disorder and/or their parents and (2) anesthesia or radiographic departments. Publications were not limited by date or study design.

RESULT

Out of 13,389 bibliographic records, nine studies were eligible for synthesis. After another search in October 2022, one additional study was eligible for synthesis.None of the studies reported children's experiences, and all ten reported their parents' experiences. Only one study was conducted in a radiographic context. Parents' experiences were both positive and negative and were categorized into two main categories: (1) challenges in a new environment and (2) health care professionals' approaches.

CONCLUSION

Studies describing children's experiences with procedures in high technology environments are lacking. The parents described a need for health care professionals to work in structured ways with their child and to be able to make suitable adaptations.

SYSTEMATIC REVIEW REGISTRATION

This systematic review was registered in advance on the Open Science Framework, https://doi.org/10.17605/OSF.IO/5TXWJ .

Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia

BACKGROUND

Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers.

METHODS

We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals' peers, defined as the proportion of a prescribers' professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after.

RESULTS

Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers.

CONCLUSIONS

The uptake of PSS in BC was highly dependent on the behavior of prescribers' peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.

A study protocol for implementing Canadian Practice Guidelines for Treating Children and Adolescents with Eating Disorders

BACKGROUND

Eating disorders have one of the highest mortality rates among psychiatric illnesses. Timely intervention is crucial for effective treatment, as eating disorders tend to be chronic and difficult to manage if left untreated. Clinical practice guidelines play a vital role in improving healthcare delivery, aiming to minimize variations in care and bridge the gap between research and practice. However, research indicates an active guideline implementation approach is crucial to effective uptake.

METHODS

Mixed methods will be used to inform and evaluate our guideline implementation approach. Semi-structured focus groups will be conducted in each of the eight provinces in Canada. Each focus group will comprise 8-10 key stakeholders, including clinicians, program administrators, and individuals with lived experience or caregivers. Qualitative data will be analyzed using conventional content analysis and the constant comparison technique and the results will be used to inform our implementation strategy. The study will then evaluate the effectiveness of our implementation approach through pre- and post-surveys, comparing changes in awareness, use, and impact of the guidelines in various stakeholder groups.

DISCUSSION

Through a multifaceted implementation strategy, involving the co-creation of educational materials, tailored training, and context-specific strategies, this study intends to enhance guideline uptake and promote adherence to evidence-based practices. Our study will also contribute valuable information on the impact of our implementation strategies.

Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study

OBJECTIVES

Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program.

DESIGN

Before-and-after observational study.

SETTING

Single-center French university teaching hospital.

PARTICIPANTS

Adult patients scheduled for cardiac surgery.

INTERVENTIONS

Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation.

MEASUREMENTS AND MAIN RESULTS

Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p = 0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p = 0.025). These effects persisted at day 30 after surgery (p = 0.029).

CONCLUSION

A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.

Investigating physicians' views on non-formulary prescribing: a qualitative study using the theoretical domains framework

BACKGROUND

Well-designed and well-maintained drug formularies serve as a reliable resource to guide prescribing decisions; they are associated with improved medicine safety and increased efficiency, while also serving as a cost-effective tool to help manage and predict medicine expenditure. Multiple studies have investigated the inappropriate prescribing of non-formulary drugs (NFDs) with statistics indicating that up to 70% of NFD usage being inappropriate or not following the ascribed NFD policies.

AIM

To explore physicians' views and influences on their prescribing of non-formulary drugs.

METHOD

Data collection and analysis were underpinned using the Theoretical Domains Framework (TDF). Thirteen semi-structured interviews were conducted within Hamad Medical Corporation, the main provider of secondary and tertiary healthcare in Qatar, with physicians who had submitted a NFD request in the preceding 12 months.

RESULTS

Three overarching themes were identified: providing evidence-based care for individual patients; influences of others; and formulary management issues. Subthemes were mapped to specific TDF domains: environmental context and resources; social influences; professional role and identity; beliefs about consequences; goals; intentions.

CONCLUSION

The behavioral influences identified in this study can be mapped to behavior change strategies facilitating the development of an intervention to promote appropriate prescribing of NFDs with implications for medicine safety and healthcare efficiency.

Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration

OBJECTIVE

To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients.

METHODS

Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021.

RESULTS

Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients.

CONCLUSIONS

Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders.

GP preferences for, access to, and use of evidence in clinical practice: a mixed-methods study

BACKGROUND

GPs aim to provide patient-centred care combining clinical evidence, clinical judgement, and patient priorities. Despite a recognition of the need to translate evidence to support patient care, barriers exist to the use of evidence in practice.

AIM

To ascertain the needs and preferences of GPs regarding evidence-based guidance to support patient care. The study also aimed to prioritise content and optimise structure and dissemination of future evidence-based guidance.

DESIGN & SETTING

This was a convergent parallel mixed-methods study in collaboration with the national GP professional body in the Republic of Ireland (Irish College of General Practitioners [ICGP]). Quantitative and qualitative findings were integrated at the interpretive level.

METHOD

A national GP survey was administered via the ICGP (December 2020) and seven GP focus groups were undertaken (April-May 2021).

RESULTS

Of 3496 GPs, a total of 509 responders (14.6%) completed the survey and 40 GP participants took part in focus groups. Prescribing updates, interpretation of test results, chronic disease management, and older person care were the preferred topics for future evidence-based guidance. GPs reported that they required rapid access to up-to-date and relevant evidence summaries online for use in clinical practice. Access to more comprehensive reviews for the purposes of continuing education and teaching was also a priority. Multimodal forms of dissemination were preferred to increase uptake of evidence in practice.

CONCLUSION

GPs indicated that rapid access to up-to-date, summarised evidence-based resources, available from their professional organisation, is preferred. Evidence should reflect the disease burden of the population and involve multifaceted dissemination approaches.

Assessment of infection control in oral radiology during the COVID-19 outbreak: An international collaborative study

Purpose

In the context of COVID-19, studies evaluating the adherence of dentists and dental students to infection control are relevant due to their high occupational exposure and risk, as well as their responsibility for disseminating information and good practices. This study evaluated the adherence of dentists and dental students to infection control in the oral radiology field in the setting of the COVID-19 pandemic on different continents.

Materials and Methods

This cross-sectional observational study involved individuals who performed intraoral radiographic examinations during the COVID-19 pandemic. The Questionnaire on Infection Control in Oral Radiology was administered virtually using a Google Form. Participants from different continents (the Americas, Africa, Europe, Asia, and Oceania) were recruited. Data were subjected to descriptive analysis and simple and multiple binary regression (5%).

Results

There were 582 valid answers, and 68.73% of the participants were from the Americas, 18.90% from Europe, and 12.37% from Asia. The median score for infection control protocols was 94 points for dental students and 104 points for dentists, and participants below the median were considered to have low adherence to infection control in oral radiology. Low access to infection control was found for 53.0% of dentists in the Americas, 34.0% from Europe, and 26.9% from Asia.

Conclusion

The adherence to infection control protocols in oral radiology was low even in the face of the COVID-19 pandemic. The results may help improve the awareness of students and professionals, since oral radiology routines have the potential for transmitting COVID-19.

Mobile-Enhanced Family-Integrated Care for Preterm Infants: Nurse and Physician Views About Implementation

BACKGROUND

The mobile-enhanced family-integrated care (mFICare) model addresses inconsistencies in family-centered care (FCC) delivery, with an evidence-based bundle of staff training, parent participation in rounds, parent classes, parent peer mentors, expanded role for parents in infant caregiving, and a parent-designed app.

PURPOSE

Our aim was to explore the views of neonatal intensive care unit (NICU) nurses and physicians about mFICare implementation, including what worked well and what could be improved.

METHODS

As part of a larger study to compare mFICare with FCC, we invited registered nurses, nurse practitioners, and fellow and attending physicians at the 3 study sites to participate in a survey about mFICare implementation. Data were analyzed with descriptive statistics and thematic analysis.

RESULTS

The majority of the 182 respondents with experience delivering mFICare positively rated parent-led rounds, parent classes, parent skills acquisition, and the nurse-family relationship resulting from participation in mFICare. Respondents were less familiar or neutral regarding the parent peer mentor and app components of mFICare. Most respondents agreed that the mFICare program improved parent empowerment, and they shared suggestions for optimizing implementation. Physicians experienced more challenges with parent participation in rounds than nurses. Three themes emerged from the free-text data related to emotional support for parents, communication between staff and parents, and the unique experiences of families receiving mFICare.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The mFICare program was overall acceptable to nurses and physicians, and areas for improvement were identified. With implementation refinement, mFICare can become a sustainable model to enhance delivery of FCC in NICUs.

Overcoming barriers to opioid-induced constipation management in cancer patients

PURPOSE

Opioid-induced constipation (OIC) is a common adverse effect of opioid therapy. We aim to identify the main barriers hindering clinical recommendations implementation and propose consensus solutions to improve OIC control in cancer patients.

METHODS

Following collaborative and prioritization techniques, a scientific committee generated statements addressing possible barriers to optimal OIC management (related to patients, health providers and health care system), and potential interventions to overcome these barriers. An expert panel of 36 oncologists assessed the statements to reach a consensus.

RESULTS

The survey consisted of 70 statements. Consensus was reached on 12/45 items related to barriers (26.6%) and on 19/25 items about corrective interventions (76%). The panel considered that patients are unaware of the existence of a specific OIC treatment, and their information sources are highly variable and unreliable. Regarding health providers, the panel considered that the oncologists prioritize symptoms such as diarrhea, pain, anxiety, or other treatment toxicities, over constipation. Work overload and bureaucratic requirements were the main barriers related to health care system. Regarding potential interventions, best-rated proposals included specific training programs development for primary care physicians and nurses, and multiplatform informative resources development for patients and caregivers, including precisely written instructions about OIC recognition and management. Oncologists assessed positively measures aiming to improve coordination between primary care physicians and oncologists, and nursing consultations implementation. The panel considered useful the OIC treatment algorithms simplification.

CONCLUSIONS

The expert panel identified the main barriers to optimal OIC management and suggested some feasible approaches to overcome these barriers.

A smartphone-based intervention for young people who self-harm ('PRIMARY'): study protocol for a multicenter randomized controlled trial

BACKGROUND

Self-harm in young people is a public health concern connected with severe mental health problems, such as personality pathology. Currently, there are no specific evidence-based interventions available for young people who self-harm. Therefore, we developed PRe-Intervention Monitoring of Affect and Relationships in Youth (PRIMARY), a smartphone-based intervention, co-designed by clinicians and young people with lived experience of mental ill-health. PRIMARY combines the Experience Sampling Method (ESM) with weekly report sessions. The study aims to examine the effectiveness of PRIMARY with regard to reducing self-harm, and improving emotion regulation and quality of relationships.

METHODS

This study is a multicenter, parallel groups, randomized controlled trial (RCT) comparing the PRIMARY intervention to a waiting list control group. PRIMARY comprises 28 consecutive days of questionnaires five times each day (i.e., ESM) and four weekly report sessions. Participants will comprise 180 young people referred for treatment to the participating Dutch mental healthcare institutions and (1) are aged 12 to 25 years, and (2) engaged in ≥ 1 act of self-harm in the past year. Participants are randomly allocated to a study group after screening in a 1:1 ratio by an independent researcher using computer-generated randomization sequences with stratified block randomization by age (12 to 15 years / 16 to 25 years). Staff will conduct assessments with all participants at baseline (Wave 1), after 28 days (Wave 2), and in a subsample after 10 weeks of subsequent specialized treatment (Wave 3). The primary outcomes are self-harm, emotion regulation, and quality of relationships. Secondary outcomes include patient and clinician satisfaction. Exploratory analyses of ESM data will examine the relationship between emotions, social relationships, and self-harm.

DISCUSSION

The results of this trial will clarify whether an innovative smartphone-based intervention is effective for reducing self harm and improving emotion regulation and the quality of social relationships. It has the potential to fill a treatment gap of interventions specifically targeting self-harm. If proven effective, it would provide an accessible, easy-to-implement, low-cost intervention for young people. Furthermore, the ESM-data will allow detailed analyses into the processes underlying self-harm, which will contribute to theoretical knowledge regarding the behavior.

TRIAL REGISTRATION

ISRCTN42088538 ( https://doi.org/10.1186/ISRCTN42088538 ), retrospectively registered on the 26th of October 2022.

The Impact of COVID-19 on Knowledge, Beliefs, and Practices of Ni-Vanuatu Health Workers Regarding Antibiotic Prescribing and Antibiotic Resistance, 2018 and 2022: A Mixed Methods Study

Antimicrobial resistance (AMR) is included in the ten most urgent global public health threats. Global evidence suggests that antibiotics were over prescribed during the early waves of the COVID-19 pandemic, particularly in low- and middle-income countries. Inappropriate use of antibiotics drives the emergence and spread of antibiotic resistance. This study aimed to examine the impact of COVID-19 on Ni-Vanuatu health worker knowledge, beliefs, and practices (KBP) regarding antibiotic prescribing and awareness of antibacterial AMR. A mixed methods study was conducted using questionnaires and in-depth interviews in 2018 and 2022. A total of 49 respondents completed both baseline (2018) and follow-up (2022) questionnaires. Knowledge scores about prescribing improved between surveys, although health workers were less confident about some prescribing activities. Respondents identified barriers to optimal hand hygiene performance. More than three-quarters of respondents reported that COVID-19 influenced their prescribing practice and heightened their awareness of ABR: "more careful", "more aware", "stricter", and "need more community awareness". Recommendations include providing ongoing continuing professional development to improve knowledge, enhance skills, and maintain prescribing competency; formalising antibiotic stewardship and infection, prevention, and control (IPC) programmes to optimise prescribing and IPC practices; and raising community awareness about ABR to support more effective use of medications.

Perspectives from clinicians and managers: facilitators and barriers to the uptake of rehabilitation guidance for children with arthrogryposis

PURPOSE

To identify the perceived facilitators and barriers among clinicians and managers about the uptake of expert guidance for rehabilitation of children with arthrogryposis multiplex congenita (AMC) in practice.

METHODS

Qualitative study using individual interviews, guided by the Theoretical Domains Framework (TDF), to explore beliefs and to identify facilitators and barriers to guidance uptake. Interviews were conducted with a convenience sample of 15 clinicians working with children with AMC and four pediatric clinical managers using Microsoft Teams©. Interviews were then transcribed verbatim and analyzed by four independent reviewers using deductive and inductive coding.

RESULTS

The TDF domains of Environmental Context and Resources, Behavioural Regulation, Reinforcement, Beliefs about Consequences, and Social Influences were shared amongst clinicians and clinical managers across North America and Europe as being relevant and influential on the target behaviour of using rehabilitation expert guidance to manage pediatric patients. Among clinicians only, the domain Memory, Attention, and Decision-Making Processes was also found relevant. Among managers only, the domain Social/Professional Role and Identity was found relevant.

CONCLUSIONS

Coupling shared relevant domains amongst clinicians and managers with individual supports and barriers helps to map out what is needed to promote the uptake of rehabilitation guidance at multiple levels.

The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature

OBJECTIVES

To identify barriers and facilitators of clinical practice guidelines (CPGs) implementation, and map those factors to the theoretical domains framework (TDF) and behavior change wheel (BCW).

METHODS

We conducted an umbrella review of systematic reviews. PubMed, Embase, and the Cochrane Library were searched. Two investigators independently screened the studies, extracted the data, and assessed the methodological quality. The identified barriers and facilitators of CPG implementation were categorized and mapped to the TDF domains and BCW components.

RESULTS

Thirty-seven studies were included, and 193 barriers and 140 facilitators were identified. Intrinsic aspects (35 barriers and 28 facilitators) mainly included the CPGs' impracticality, complexity, and inaccessibility. Extrinsic aspects (158 barriers and 113 facilitators) mainly included lack of resources, training, funding, or awareness of CPG content in barriers; audits and feedback; strong leadership and management support; and educating and training about CPGs in facilitators. Environmental context and resources (n = 97, 19.48%) were the most reported barriers in TDF domains. Physical opportunity and social opportunity were the most frequently mentioned models in BCW.

CONCLUSION

Multiple barriers and facilitators for healthcare CPG implementation are identified, with further links to TDF and BCW. Future knowledge translation strategies should be developed accordingly in specified health care settings.

Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives

OBJECTIVES

To explore the experiences of Australian and New Zealand clinicians with respect to care pathways, their awareness and use of non-invasive ventilation guidelines, and their perspectives on delivering quality non-invasive ventilation services to people with neuromuscular disorders.

DESIGN, SETTING, PARTICIPANTS

Qualitative study; semi-structured focus groups and individual interviews with Australian and New Zealand clinicians who provide non-invasive ventilation services to people with neuromuscular disorders, recruited from participants at a 2017 sleep medicine conference. Interviews were conducted during 1 October 2017 - 31 May 2018.

MAIN OUTCOME MEASURES

Major themes identified by an iterative, semantic, and inductive analysis.

RESULTS

A total of 28 participants attended the four focus group sessions and five individual interviews; fourteen each from New Zealand and Australia, seventeen women and eleven men, eighteen physicians and ten other clinicians. Two major themes were identified: decision making for current practice, and resource constraints. Participants noted variable use of clinical guidelines and limited training to meet the needs of people with neuromuscular disorders who require non-invasive ventilation. They described a lack of dedicated funding, unstructured care pathways, equipment supply levels that do not meet need, low staff-to-patient ratios and staff shortages, and the inability to deliver quality multidisciplinary care. The need for clinical guidelines and service specifications was highlighted as requisite for reducing variation in clinical care.

CONCLUSIONS

Systemic factors influence the needs-based provision of non-invasive ventilation for people with neuromuscular disorders. Development of clinical guidelines for Australia and New Zealand, dedicated funding for respiratory services for people with neuromuscular disorders, and specialist clinician training are important for equitable and high quality non-invasive ventilation care.

A systematic review and evaluation of post-stroke depression clinical practice guidelines

OBJECTIVE

Post-stroke depression is a depressive mood disorder that follows a cerebrovascular accident and is a burden on stroke patients. Its management is included in clinical practice guidelines focused on stroke, and the recommended treatment is selective serotonin reuptake inhibitors in conjunction with psychotherapy. Clinical practice guidelines are recommendations used to standardize best medical practice, but there is no current evaluation of guidelines containing post stroke depression recommendations. Thus, the objective is to appraise the selected guidelines manner of development and quality.

MATERIALS AND METHODS

A systematic literature review across three databases and a manual google search was performed to collect guidelines that included recommendations on the management of post-stroke depression. 1236 guidelines were screened, and 27 were considered for inclusion. Considered guidelines were manually reviewed by the authors, and ultimately, 7 met inclusion criteria. The appraisal of guidelines for research and evaluation was used to evaluate these guidelines' recommendations around post-stroke depression.

RESULTS

Three guidelines met the threshold considered "High", with all of them having five or more quality domains eclipse the cutoff score of 70%. Across all guidelines, the highest scoring domains were "Scope and Purpose", "Clarity of Presentation", and "Editorial Independence" with scores of 76.98%, 73.81%, and 91.36% respectively. The lowest scoring domains were "Applicability", "Rigor of Development", and "Stakeholder Involvement" with respective scores of 58.73%, 54.02%, and 43.90%.

CONCLUSIONS

The domains "Applicability", "Rigor of Development," and "Stakeholder Involvement" were the lowest scoring domains. These specific domains represent areas in which future guidelines could be more developed.

An Integrated Process for Co-Developing and Implementing Written and Computable Clinical Practice Guidelines

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes.

Chinese Registry of Psoriatic Arthritis (CREPAR): I. Clinical characteristics of Chinese patients with psoriatic arthritis

AIM

To describe the clinical characteristics of Chinese patients with psoriatic arthritis (PsA) using the data recorded in the Chinese Registry of Psoriatic Arthritis (CREPAR).

METHODS

This is a cross-sectional study based on the CREPAR registry, which is a prospective registry founded in December 2018. Data regarding clinical characteristics and treatment of patients were collected during every visit. Data recorded at enrollment were extracted, analyzed, and compared with data in other registries or cohorts.

RESULTS

A total of 1074 patients were registered from December 2018 to June 2021. Of these, 929 (86.5%) patients had a history of peripheral arthritis, and 844 patients (78.6%) had peripheral arthritis at enrollment, of which polyarthritis is the most common subtype. Axial involvement was present in 39.9% of patients, and 50 (4.7%) patients had axial involvement only. More than half of the patients (55.4%) had at least two musculoskeletal presentations at enrollment. The prevalence of low disease activity and remission according to DAPSA were 26.4% and 6.8%, respectively. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biological DMARDs were used in 64.9% and 29.1% of patients, respectively. Among patients with different musculoskeletal presentations, patients with dactylitis had the highest proportion of nonsteroidal anti-inflammatory and csDMARD use. The proportion of patients receiving bDMARDs was highest in axial PsA.

CONCLUSION

The CREPAR registry has provided information on Chinese patients with PsA. Compared with data in other registries or cohorts, the disease activity of patients in CREPAR was higher, and the proportion of bDMARD use was lower.

Conventional and living guideline for schizophrenia: barriers and facilitating factors in guideline implementation

This study aims to investigate the barriers and facilitators to guideline adherence for the print format of the German schizophrenia guideline as well as for the concept of a digital living guideline for the first time. For this purpose, the schizophrenia guideline was transferred to a digital guideline format within the web-based tool MAGICapp. An online survey was performed under participation of mental healthcare professionals (medical doctors, psychologists/psychotherapists, psychosocial therapists, caregivers) in 17 hospitals for psychiatry in Southern Germany and a professional association for German neurologists and psychiatrists. 524 participants opened the survey, 439 completed the demographic questions and commenced the content-related survey and 309 provided complete data sets. Results indicate a higher occurrence of knowledge-related barriers for the living guideline. The print version is associated with more attitude-related and external barriers. Older professionals reported more attitude-related barriers to a living guideline compared to younger professionals. Differences between professions regarding barriers were found for both formats. Various barriers exist for both guideline formats and a need for facilitators was expressed across professions. Many of the mentioned obstacles and facilitators can be more easily addressed with living guidelines. However, also living guidelines face barriers. Thus, the introduction of these new formats alone cannot lead to sustainable behavior change regarding guideline adherence. Yet, living guidelines seem to be a cornerstone to improved and tailored guideline implementation as they facilitate to keep recommendations up to date and to address the need of individual professional groups.

Interventions for the uptake of evidence-based recommendations in acute stroke settings

BACKGROUND

There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care.

OBJECTIVES

To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations.

MAIN RESULTS

We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes.

AUTHORS' CONCLUSIONS

We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.

Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study

OBJECTIVES

Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements.

METHODS

A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted.

RESULTS

Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs.

CONCLUSIONS

Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.

Sharing voice during deliberative engagement to improve guideline adherence in dental clinics: findings from a qualitative evaluation of an online deliberative forum discussion

OBJECTIVES

Selecting effective implementation strategies to support guideline-concordant dental care is a complex process. For this research project, an online deliberative forum brought together staff from dental clinics to discuss the strengths and weaknesses of implementation strategies and barriers to implementation of a component of a dental (pit-and-fissure) guideline. The goal was to determine whether deliberative engagement enabled participants' sharing of promotive and prohibitive voice about implementation strategies to promote guideline-concordant care.

DESIGN

Qualitative analysis of online chat transcripts of facilitated deliberations from 31 small group sessions.

SETTING

Kaiser Permanente Dental (KP Dental) in the USA.

PARTICIPANTS

All staff from 16 dental offices.

RESULTS

The directed content analysis revealed that participants shared prohibitive and promotive voice when offering critique of the barriers and the implementation strategies suggested by the researchers. The analysis also revealed that the focus of the deliberations often was not on the aspect of the pit-and-fissure guideline intended by the research team for deliberation.

CONCLUSIONS

The deliberative forum discussions were a productive venue to ask staff in dental clinics to share their perspectives on strategies to promote guideline-concordant care as well as barriers. Participants demonstrated prohibitive voice and engaged critically with the materials the research team had put together. An important limitation of the deliberation was that the discussion often centred around an aspect of the pit-and-fissure guideline that already was implemented well. To ensure a deliberation oriented towards resolving challenging aspects of the pit-and-fissure guideline, greater familiarity with the guideline would have been important, as well as more intimate knowledge of the current discrepancies in guideline-concordant care.

TRIAL REGISTRATION NUMBER

This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 18 December 2020. https://clinicaltrials.gov/ct2/show/NCT04682730.

Can language enhance physical therapists' willingness to follow Choosing Wisely recommendations? A best-worst scaling study

BACKGROUND

Choosing Wisely recommendations could reduce physical therapists' use of low-value care.

OBJECTIVE

To investigate whether language influences physical therapists' willingness to follow the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations.

DESIGN

Best-worst Scaling survey METHODS: The six original APA Choosing Wisely recommendations were modified based on four language characteristics (level of detail, strength- qualified/unqualified, framing, and alternatives to low-value care) to create 60 recommendations. Physical therapists were randomised to a block of seven choice tasks, which included four recommendations. Participants indicated which recommendation they were most and least willing to follow. A multinomial logistic regression model was used to create normalised (0=least preferred; 10=most preferred) and marginal preference scores.

RESULTS

215 physical therapists (48.5% of 443 who started the survey) completed the survey. Participants' mean age (SD) was 38.7 (10.6) and 47.9% were female. Physical therapists were more willing to follow recommendations with more detail (marginal preference score of 1.1) or that provided alternatives to low-value care (1.3) and less willing to follow recommendations with negative framing (-1.3). The use of qualified ('don't routinely') language (vs. unqualified - 'don't') did not affect willingness. Physical therapists were more willing to follow recommendations to avoid imaging for non-specific low back pain (3.9) and electrotherapy for low back pain (3.8) vs. recommendation to avoid incentive spirometry after upper abdominal and cardiac surgery.

CONCLUSION

Physical therapists were more willing to follow recommendations that provided more detail, alternatives to low-value care, and were positively framed. These findings can inform the development of future Choosing Wisely recommendations and could help reduce low-value physical therapy.

Assessing Adherence to Clinical Practice Guidelines Among Primary Care Physicians in Bahrain: A Cross-sectional Study

Objectives

To assess the adherence to clinical practice guidelines (CPGs) and explore the barriers to their implementation among primary care physicians (PCPs) in Bahrain.

Methods

A cross-sectional study was conducted using an online survey among physicians working in 20 randomly selected public sector primary health centers in Bahrain. Private-sector physicians and family medicine residents were excluded. Outcome measures were assessing the extent of adherence to CPGs, describing the results in association with work roles, gender, level of formal training, and years of working experience, and investigating the barriers to adhering to CPGs.

Results

The subjects were 149 PCPs (consultants, specialists, and general practitioners) working in government primary health centers. The vast majority (98.0%) reported that they implemented CPGs in their daily practice. The most commonly cited reason (79.2%) for implementation was that the CPGs were evidence-based. The most implemented guidelines pertained to diabetes (91.3%), hypertension (81.2%), and hyperlipidemia (69.8%). The least implemented ones were screening of women (38.9%) and postnatal care (45.6%). The level of formal medical training was associated with the implementation of CPGs on preventive care, antenatal and postnatal care, and children and women screening (p < 0.05). Hypertension and bronchial asthma guidelines were implemented more by male physicians (p < 0.05) while female physicians were more adherent to CPGs on antenatal and postnatal care, and women and child screening (p < 0.05). The main barrier reported by the physicians was that they wished to know more about CPGs before applying them (mean ± SD = 3.8 ± 0.9). The perception that managers or directors are non-cooperative towards the application of CPGs was associated with years of experience (p = 0.008) and the position of the physician (p = 0.028). General practitioners were more likely to consider non-cooperation from patients as a barrier (p = 0.025).

Conclusions

Most PCPs in Bahrain are adherent to CPGs in their daily practice and encounter minimal barriers. Identifying and resolving barriers can help develop unified and standardized guidelines that promote better consistency in patient management, minimize medical errors, and conserve resources.

In search of factors related to migration affecting children's health - an analysis of documents guiding health visits within the Swedish school health services

BACKGROUND

Migration affects the health of children worldwide. Therefore, school nurses who encounter these children as part of their everyday practice need support from guidelines on how to promote the health of children who have migrated or whose parents have migrated. Yet knowledge regarding such content in guidelines of school nursing practice is sparse. Therefore, this study aims to investigate how municipal and regional guidelines and health questionnaires used in health visits in the Swedish school health services include factors related to migration that affect children's health.

METHODS

A document analysis of municipal and regional guidelines and health questionnaires guiding school nurses' practice in health visits was conducted during the autumn of 2020. In total, 687 guidelines and health questionnaires were analyzed using deductive content analysis.

RESULTS

The results show that municipal and regional guidelines and health questionnaires used in health visits in the Swedish school health services include content on many factors related to migration that affect children's health. Yet the content was limited, and none was found on factors related to discrimination based on ethnicity or origin.

CONCLUSION

Guidance related to promoting the health of children who have migrated or whose parents have migrated should include all factors affecting these children's health. Therefore, to strengthen school nurses' evidence-based practice, guideline development might be needed, although guidelines and health questionnaires exist and include content on many factors related to migration affecting the health of children in order to provide equitable healthcare for all children, regardless of country of origin.

Nutritional Intake after Liver Transplant: Systematic Review and Meta-Analysis

Cardiovascular disease and its concurrent risk factors are prevalent after liver transplant (LT). Most of these risk factors are modifiable by diet. We aimed to synthesise the literature reporting the nutritional intake of liver transplant recipients (LTR) and the potential determinants of intake. We performed a systematic review and meta-analyses of studies published up until July 2021 reporting the nutritional intake of LTR. The pooled daily mean intakes were recorded as 1998 (95% CI 1889, 2108) kcal, 17 (17, 18)% energy from protein, 49 (48, 51)% energy from carbohydrates, 34 (33, 35)% energy from total fat, 10 (7, 13)% energy from saturated fat, and 20 (18, 21) g of fibre. The average fruit and vegetable intake ranged from 105 to 418 g/day. The length of time post-LT and the age and sex of the cohorts, as well as the continent and year of publication of each study, were sources of heterogeneity. Nine studies investigated the potential determinants of intake, time post-LT, gender and immunosuppression medication, with inconclusive results. Energy and protein requirements were not met in the first month post-transplant. After this point, energy intake was significantly higher and remained stable over time, with a high fat intake and low intake of fibre, fruits and vegetables. This suggests that LTR consume a high-energy, low-quality diet in the long term and do not adhere to the dietary guidelines for cardiovascular disease prevention.

Co-developed implementation guidelines to maximize acceptability, feasibility, and usability of mobile phone supervision in Kenya

Opportunities exist to leverage mobile phones to replace or supplement in-person supervision of lay counselors. However, contextual variables, such as network connectivity and provider preferences, must be considered. Using an iterative and mixed methods approach, we co-developed implementation guidelines to support the implementation of mobile phone supervision with lay counselors and supervisors delivering a culturally adapted trauma-focused cognitive behavioral therapy in Western Kenya. Guidelines were shared and discussed with lay counselors in educational outreach visits led by supervisors. We evaluated the impact of guidelines and outreach on the acceptability, feasibility, and usability of mobile phone supervision. Guidelines were associated with significant improvements in acceptability and usability of mobile phone supervision. There was no evidence of a significant difference in feasibility. Qualitative interviews with lay counselors and supervisors contextualized how guidelines impacted acceptability and feasibility - by setting expectations for mobile phone supervision, emphasizing importance, increasing comfort, and sharing strategies to improve mobile phone supervision. Introducing and discussing co-developed implementation guidelines significantly improved the acceptability and usability of mobile phone supervision. This approach may provide a flexible and scalable model to address challenges with implementing evidence-based practices and implementation strategies in lower-resourced areas.

Relationship between guideline adherence and outcomes in severe traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of death and morbidity worldwide. Evidence-based guidelines for managing severe TBI have been available for over 25 years. However, adherence to guidelines remains variable despite evidence highlighting improvement in outcomes with individual recommendations. There is limited evidence to support a superior outcome with compliance to whole sets of recommendations. The aim of this review was to determine whether adherence to TBI guidelines as a package improves outcomes in adults and paediatric patients with severe TBI.

METHODS

A structured literature search was conducted using the MEDLINE®, Embase™, PubMed and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases. Studies were considered eligible for inclusion in this review if they were quantitative studies investigating the use of TBI guidelines in relation to one or more of the following outcomes: mortality, functional outcome and length of hospital stay.

RESULTS

Nine cohort studies were identified that fulfilled the inclusion criteria and answered the clinical question. A review of these papers was conducted.

CONCLUSIONS

Mortality after severe TBI improves with increasing adherence to evidence-based guidelines in both adults and children. The evidence also suggests that compliance with guideline recommendations results in improved functional outcomes and reduced length of hospital stay.

Healthcare professionals' perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review

OBJECTIVE

To identify healthcare professionals' perceived barriers and facilitators to clinical practice guideline implementation within stroke rehabilitation.

DATA SOURCES

CINAHL, MEDLINE, EMBASE, AMED, Cochrane library, Academic Search Complete and Scopus. Additional papers were identified through hand searching.

REVIEW METHODS

The review followed the Preferred Reporting Item for Systematic Reviews and Meta-Analysis Protocols systematic review approach. Any empirical research that provided qualitative data on healthcare professionals' perceived factors influencing clinical guideline implementation in stroke rehabilitation was included. One reviewer screened all titles and abstract reviews (n = 669). Another two reviewers independently screened 30% of title and abstract reviews, followed by full-text reviews (n = 61). Study quality was assessed using the mixed-method appraisal tool.

RESULTS

Data from 10 qualitative, six quantitative and six mixed-method studies published between 2000 and 2022, involving 1576 participants in total, were analysed and synthesised using modified thematic synthesis approach. The majority of participants were therapists n = 1297 (occupational therapists, physiotherapists, speech and language therapists). Organisational factors (time constraints, resources) alongside healthcare professionals' lack of knowledge and skills were the most cited barriers to guideline implementation. Contradictory attitudes and beliefs towards stroke guidelines applicability to real-life clinical practice and their evidence base were reported. Organisational support in the form of training, local protocols, performance monitoring and leadership were reported as perceived facilitators.

CONCLUSION

Barriers and facilitators are multifactorial and were identified at guideline, individual, team and organisational levels. There is a need to translate perceived barriers and facilitators into implementation interventions especially addressing organisational-level barriers.

Lipid treatment status and goal attainment among patients with premature acute coronary syndrome in Israel

BACKGROUND

There are significant health gaps between Arabs and Jews in Israel. However, there are limited data on the management and treatment of dyslipidemia among Israeli adults who experience premature acute coronary syndrome (ACS). This study aimed to assess the differences between Arabs and Jews with regard to lipid-lowering therapy administration and low-density lipoprotein cholesterol (LDL-C) levels goal attainment at 1 year post-ACS.

METHODS

This study included patients aged ≤55 years who had been hospitalized for ACS at Meir Medical Center between 2018 and 2019. Outcomes included the rate of use of lipid-lowering medications, LDL-C levels 1 year post-admission, and major adverse cardiovascular and cerebrovascular events (MACCE) during 30 months of follow-up.

RESULTS

The study population comprised 687 young adults with a median age of 48.5 years. 81.9% of the Arab patients and 79.8% of the Jewish patients were discharged on high intensity statins. At 1 year of follow-up, the proportions of Arab patients who had LDL-C levels <70 mg/dL and <55 mg/dL were lower than those of Jewish patients (43.8% vs. 58%, p < 0.001 and 34.5% vs. 45.3%, p < 0.001, respectively). At 1 year of follow-up, only 25% and 4% of both groups were treated with ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor. The incidence of MACCE was significantly higher among Arab patients.

CONCLUSION

Our study highlighted the need for a more aggressive lipid-lowering strategy in both Arab and Jewish populations. Culturally adapted interventions are required to reduce gaps between Arab and Jewish patients.

A Process Evaluation of the National Implementation of a Bundle for Central Venous Catheter Care for Hemodialysis

Key Points

Health professionals resisted practice change in environments of low infection where the perception of a need to change is small. Standardizing care of central venous catheters for hemodialysis requires breaking down silos of practice to benefit all patients. Knowledge of and adherence to guidelines, formal change management, and ongoing facilitation are required to implement standardized care.

Background

Implementation of a care bundle standardizing insertion, management, and removal practices to reduce infection related to central venous catheters (CVCs) used for hemodialysis was evaluated in a stepped wedge, cluster randomized controlled trial conducted at 37 Australian hospitals providing kidney services, with no reduction in catheter-related blood stream infection detected. This process evaluation explored the barriers, enablers, and unintended consequences of the implementation to explain the trial outcomes.

Methods

Qualitative process evaluation using pre-post semistructured interviews with 38 (19 nursing and 19 medical) and 44 (25 nursing and 19 medical) Australian health professionals involved in hemodialysis CVC management. Analysis was guided by the process implementation domain of the Consolidated Framework for Implementation Research.

Results

Key influences on bundle uptake were that clinicians were open to change that was evidence-based and driven by guidelines and had a desire to improve practice and patient outcomes. However, resistance to change in environments of low infection, working in silos of practice, and a need for individualized delivery of patient education created barriers to uptake. Unintended effects of increased costs and lack of interoperability of systems for data collection were reported. Because the trial was in progress at the time of qualitative data collection, perceptions of the bundle may have been influenced by the fact that practices of participants were being observed as a part of the trial.

Conclusion

This national process evaluation revealed that health professionals who reported experiencing a benefit viewed the bundle positively. Those who already provided most of the recommended care or perceived that their patient population was not included in the research evidence that underpinned the interventions, resisted the implementation of the bundle. Potentially, formal change management processes using facilitation may improve implementation of evidence-based practice.

Clinical Trial registry name and registration number:

Australian New Zealand Clinical Trials Registry, ACTRN12616000830493 .

Creating implementable clinical practice guidelines: the 2020 Focused Updates to the National Heart, Lung, and Blood Institute's Asthma Management Guidelines

BACKGROUND

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group provides the first new clinical practice recommendations from the National Heart, Lung, and Blood Institute (NHLBI) since the previous 2007 asthma management guidelines. Guideline implementability was a high priority for the expert panel, and many approaches were undertaken to enhance the implementability of this clinical guideline update. Within the report, specific implementation guidance sections provide expanded summaries for each recommendation to quickly assist users. The implementation guidance incorporates findings from NHLBI-sponsored focus groups conducted with people who have asthma, caregivers, and health care providers. The findings were used to identify the types of information and tools that individuals with asthma, their caregivers, and their health care providers would find most helpful; ensure that the new asthma guidelines reflect the voices of individuals with asthma and their caregivers; and identify potential barriers to uptake by individuals with asthma and their caregivers. The expert panel used a GRADE-based approach to develop evidence-to-decision tables that provided a framework for assessing the evidence and consideration of a range of contextual factors that influenced the recommendations such as desirable and undesirable effects, certainty of evidence, values, balance of effects, acceptability, feasibility, and equity. To facilitate uptake in clinical care workflow, selected recommendations were converted into structured, computer-based clinical decision support artifacts, and the new recommendations were integrated into existing treatment tables used in the 2007 asthma management guidelines, with which many users are familiar. A comprehensive approach to improve guidelines dissemination and implementation included scientific publications, patient materials, media activities, stakeholder engagement, and professional education.

CONCLUSION

We developed evidence-based clinical practice guideline updates for asthma management focused on six topic areas. The guideline development processes and implementation and dissemination activities undertaken sought to enhance implementability by focusing on intrinsic factors as described by Kastner, Gagliardi, and others to produce usable, adoptable, and adaptable guidelines. Enhanced collaboration during guideline development between authors, informaticists, and implementation scientists may facilitate the development of tools that support the application of recommendations to further improve implementability.

Strong recommendations from low certainty evidence: a cross-sectional analysis of a suite of national guidelines

BACKGROUND

Clinical guidelines should be based on a thorough evaluation of the evidence and generally include a rating of the quality of evidence and assign a strength to recommendations. Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance warns against making strong recommendations when the certainty of the evidence is low or very low, but has identified five paradigmatic situations (e.g. life-threatening situations) where this may be justified.

AIMS AND OBJECTIVES

We aimed to characterize the strength of recommendations and certainty of the evidence in Irish National Clinical Guidelines using the GRADE approach.

METHODS

All National Clinical Guidelines from the National Clinical Effectiveness Committee (NCEC) website using the GRADE approach (fully or partially) were included. All recommendations and their corresponding certainty of the evidence, strength of recommendations and justifications were extracted. Authors classified instances of strong recommendations with low certainty evidence (referred to as discordant recommendations) into one of the five paradigmatic situations. Descriptive statistics were calculated.

RESULTS

From the 29 NCEC Clinical Guidelines available at the time of analysis, we identified 8 guidelines using GRADE with a total of 240 recommendations; 38 recommendations did not use the GRADE approach and were excluded. Half of the included guidelines focused on emergency situations. In the final dataset of 202 recommendations, 151 (74.7%) were classified as strong and 51 (25.3%) as conditional. Of the 151 strong recommendations, 55 (36.4%) were supported by high or moderate certainty evidence and 96 (63.6%) by low or very low certainty evidence and were considered discordant. Of these 96 discordant recommendations, 55 (73.7%) were consistent with one of the five paradigmatic situations. However, none were specifically described as such within the guidelines.

CONCLUSIONS

The proportion of discordant recommendations identified in this analysis was higher than some previous international studies (range of all strong recommendations being discordant 30-50%), but similar to other guidelines focused on emergency situations. The majority of discordant recommendations could be mapped to one of the five situations, but no National Clinical Guideline explicitly referenced this. Guideline developers require further guidance to enable greater transparency in the reporting of the reasons for discordant recommendations.