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Lynch EA, Bulto LN, Cheng H, Craig L, Luker JA, Bagot KL, Thayabaranathan T, Janssen H, McInnes E, Middleton S, Cadilhac DA. Interventions for the uptake of evidence-based recommendations in acute stroke settings. Cochrane Database Syst Rev 2023; 8:CD012520. [PMID: 37565934 PMCID: PMC10416310 DOI: 10.1002/14651858.cd012520.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
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.
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Affiliation(s)
| | - Lemma N Bulto
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Heilok Cheng
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Julie A Luker
- Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Kathleen L Bagot
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
| | | | - Heidi Janssen
- School of Health Sciences, The University of Newcastle, Callaghan, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
- NSW School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Dominique A Cadilhac
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, Australia
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Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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Xu W, Liu L, Zhang J. Application Analysis Based on Big Data Technology in Stroke Rehabilitation Nursing. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:3081549. [PMID: 34900181 PMCID: PMC8654541 DOI: 10.1155/2021/3081549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022]
Abstract
According to the statistical analysis, the incidence of stroke disease has gradually increased, particularly in recent years, which poses a huge threat to the safety of human life. Due to the advancement in science and technology specifically big data and sensors, a new research dome known as data mining technology has been introduced, which has the potential value from the perspective of large amount of data analysis. Information has become a new trend of science and technology, and data mining has been used in various application areas to analyze and predict strokes at home and abroad. In this study, big data technology is utilized to collect potential information and explores clinical pathways of level-3 rehabilitation in certain regions of China. Moreover, application effects of data mining in the rehabilitation of patients with the first ischemic stroke have been evaluated and reported. For this purpose, fifty (50) first-time ischemic stroke patients have been screened through big data and were nonartificially assigned to level-3 clinical pathway and conventional rehabilitation groups, respectively, specifically through software. The first group of patients enters the clinical path of the corresponding level according to the way of three-level referral. These patients were analyzed based on the collected results of completing the unified rehabilitation treatment plan of the three-level rehabilitation medical institution in the patient record form. The second group was selected according to the routine rehabilitation model and method of the medical institution where the patients visited were divided into four stages: before treatment, three weeks after treatment, nine weeks after treatment, and seventeen weeks after treatment. For this purpose, a simplified Fugl-Meyer analysis (FMA), recording of various functions of limb movement, and modified Barthel index (MBI) scale were used to analyze and evaluate the ability of daily activities and compare their effects. The final results showed that FMA and MBI scores of the two groups were improved in the three stages after treatment. The FMA and MBI scores of the clinical pathway group on 3rd and 9th weekends were significantly different from those of the conventional rehabilitation group (which is p < 0.05). Moreover, difference in FMA and MBI scores between the two at the 17th weekend was not significant. The total cost of the clinical pathway group, particularly at the ninth weekend, was higher than that of the conventional rehabilitation group, but the cost-benefit ratio was better and the incidence of complications was lower than that of the other group.
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Affiliation(s)
- WeiHua Xu
- Department of Neurology, Hubei No. 3 People's Hospital of Jianghan University, Wuhan 430033, China
| | - LiangJin Liu
- Department of Radiology, Hubei No. 3 People's Hospital of Jianghan University, Wuhan 430033, China
| | - JiuXia Zhang
- Department of Radiology, Hubei No. 3 People's Hospital of Jianghan University, Wuhan 430033, China
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Diamant A. Dynamic multistage scheduling for patient-centered care plans. Health Care Manag Sci 2021; 24:827-844. [PMID: 34374889 DOI: 10.1007/s10729-021-09566-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/12/2021] [Indexed: 11/24/2022]
Abstract
We investigate the scheduling practices of multistage outpatient health programs that offer care plans customized to the needs of their patients. We formulate the scheduling problem as a Markov decision process (MDP) where patients can reschedule their appointment, may fail to show up, and may become ineligible. The MDP has an exponentially large state space and thus, we introduce a linear approximation to the value function. We then formulate an approximate dynamic program (ADP) and implement a dual variable aggregation procedure. This reduces the size of the ADP while still producing dual cost estimates that can be used to identify favorable scheduling actions. We use our scheduling model to study the effectiveness of customized-care plans for a heterogeneous patient population and find that system performance is better than clinics that do not offer such plans. We also demonstrate that our scheduling approach improves clinic profitability, increases throughput, and decreases practitioner idleness as compared to a policy that mimics human schedulers and a policy derived from a deep neural network. Finally, we show that our approach is fairly robust to errors introduced when practitioners inadvertently assign patients to the wrong care plan.
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Affiliation(s)
- Adam Diamant
- Schulich School of Business, York University, 111 Ian Macdonald Boulevard, Toronto, Ontario, M3J 1P3, Canada.
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Haas K, Rücker V, Hermanek P, Misselwitz B, Berger K, Seidel G, Janssen A, Rode S, Burmeister C, Matthis C, Koennecke HC, Heuschmann PU. Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke. Stroke 2020; 51:3664-3672. [DOI: 10.1161/strokeaha.120.029968] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background and Purpose:
Quality indicators (QI) are an accepted tool to measure performance of hospitals in routine care. We investigated the association between quality of acute stroke care defined by overall adherence to evidence-based QI and early outcome in German acute care hospitals.
Methods:
Patients with ischemic stroke admitted to one of the hospitals cooperating within the ADSR (German Stroke Register Study Group) were analyzed. The ADSR is a voluntary network of 9 regional stroke registers monitoring quality of acute stroke care across 736 hospitals in Germany. Quality of stroke care was defined by adherence to 11 evidence-based indicators of early processes of stroke care. The correlation between overall adherence to QI with outcome was investigated by assessing the association between 7-day in-hospital mortality with the proportion of QI fulfilled from the total number of QI the individual patient was eligible for. Generalized linear mixed model analysis was performed adjusted for the variables age, sex, National Institutes of Health Stroke Scale and living will and as random effect for the variable hospital.
Results:
Between 2015 and 2016, 388 012 patients with ischemic stroke were reported (median age 76 years, 52.4% male). Adherence to distinct QI ranged between 41.0% (thrombolysis in eligible patients) and 95.2% (early physiotherapy). Seven-day in-hospital mortality was 3.4%. The overall proportion of QI fulfilled was median 90% (interquartile range, 75%–100%). In multivariable analysis, a linear association between overall adherence to QI and 7-day in-hospital-mortality was observed (odds ratio adherence <50% versus 100%, 12.7 [95% CI, 11.8–13.7];
P
<0.001).
Conclusions:
Higher quality of care measured by adherence to a set of evidence-based process QI for the early phase of stroke treatment was associated with lower in-hospital mortality.
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Affiliation(s)
- Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, University of Würzburg (K.H., V.R., P.U.H.)
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, University of Würzburg (K.H., V.R., P.U.H.)
| | - Peter Hermanek
- Bavarian Permanent Working Party for Quality Assurance (BAQ), Munich (P.H.)
| | | | - Klaus Berger
- Quality Assurance Project ”Stroke Register Northwest Germany”, Institute of Epidemiology and Social Medicine, University of Münster (K.B.)
| | - Günter Seidel
- Department of Neurology, Asklepios Klinik Nord, Hamburg (G.S.)
| | - Alfred Janssen
- Quality Assurance in Stroke Management in North Rhine–Westphalia, Medical Association North Rhine (A.J.)
| | - Susanne Rode
- Office for Quality Assurance in Health Care Baden-Württemberg GmbH (QiG BW GmbH), Stuttgart (S.R.)
| | | | - Christine Matthis
- Quality Association for Acute Stroke Treatment Schleswig-Holstein (QugSS), Institute of Social Medicine and Epidemiology, University of Lübeck (C.M.)
| | | | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg (K.H., V.R., P.U.H.)
- Clinical Trial Center, University Hospital Würzburg (P.U.H.)
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Cahill LS, Carey LM, Lannin NA, Turville M, Neilson CL, Lynch EA, McKinstry CE, Han JX, O'Connor D. Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation. Cochrane Database Syst Rev 2020; 10:CD012575. [PMID: 33058172 PMCID: PMC8095062 DOI: 10.1002/14651858.cd012575.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence-based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation. OBJECTIVES To assess the effects of implementation interventions to promote the uptake of evidence-based practices (including clinical assessments and treatments recommended in evidence-based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non-tailored interventions in stroke rehabilitation. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies. SELECTION CRITERIA We included individual and cluster randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well-being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects. 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. The primary comparison was any implementation intervention compared to no intervention. MAIN RESULTS Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three-arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence-based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting. We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low-certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI -1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well-being (standardised mean difference (SMD) -0.02, 95% CI -0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate-certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health-related quality of life (MD 0.01, 95% CI -0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI -0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention. No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction. Five studies reported economic outcomes, with one study reporting cost-effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost-effectiveness of interventions. Tailoring interventions to identified barriers did not alter results. We are uncertain of the effect of one implementation intervention versus another given the limited very low-certainty evidence. AUTHORS' CONCLUSIONS We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low.
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Affiliation(s)
- Liana S Cahill
- Occupational Therapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
- Department of Occupational Therapy, School of Allied Health, Australian Catholic University, Fitzroy, Australia
| | - Leeanne M Carey
- Occupational Therapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Natasha A Lannin
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Allied Health, Alfred Health, Melbourne, Australia
| | - Megan Turville
- Occupational Therapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Cheryl L Neilson
- Rural Department of Allied Health, Rural Health School, La Trobe University, Bendigo, Australia
| | - Elizabeth A Lynch
- Adelaide Nursing School, The University of Adelaide, Adelaide, Australia
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health & Hunter Medical Research Institute, Melbourne and Newcastle, Australia
| | - Carol E McKinstry
- Rural Department of Allied Health, Rural Health School, La Trobe University, Bendigo, Australia
| | - Jia Xi Han
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Identifying Performance Outliers for Stroke Care Based on Composite Score of Process Indicators: an Observational Study in China. J Gen Intern Med 2020; 35:2621-2628. [PMID: 32462572 PMCID: PMC7459034 DOI: 10.1007/s11606-020-05923-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 05/11/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Variability in the quality of stroke care is widespread. Identifying performance-based outlier hospitals based on quality indicators (QIs) has become a common practice. OBJECTIVES To develop a tool for identifying performance-based outlier hospitals based on risk-adjusted adherence rates of process indicators. DESIGN Hospitals were classified into five-level outliers based on the observed-to-expected ratio and P value. The composite quality score was derived by summation of the points for each indicator for each hospital, and associations between outlier status and outcomes were determined. PARTICIPANTS Patients diagnosed with acute ischemic stroke, January 1, 2011-May 31, 2017. INTERVENTION N/A MAIN OUTCOME MEASURES: Independence at discharge (the modified Rankin Scale = 0-2). KEY RESULTS A total of 501,132 patients from 519 hospitals were identified. From 0.39 to 19.65% of hospitals were identified as high outliers according to various QIs. Composite quality scores ranged from - 20 to 16. Providers that were high outliers based on QI2, QI8, QI9, and QI11 had higher independent rates. For composite quality score, each point increase corresponded to an 8% increase in the odds of independent rate. CONCLUSION Nationwide variation in the quality of acute stroke care exists at the hospital level. Variability in the quality of stroke care can be captured by our proposed quality score. Applying this quality score as a benchmarking tool could provide audit-level feedback to policymakers and hospitals to aid quality improvement.
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Machline-Carrion MJ, Santucci EV, Damiani LP, Bahit MC, Málaga G, Pontes-Neto OM, Martins SCO, Zétola VF, Normilio-Silva K, Rodrigues de Freitas G, Gorgulho A, De Salles A, Pacheco da Silva BG, Santos JY, de Andrade Jesuíno I, Bueno PRT, Cavalcanti AB, Guimarães HP, Xian Y, Bettger JP, Lopes RD, Peterson ED, Berwanger O. Effect of a Quality Improvement Intervention on Adherence to Therapies for Patients With Acute Ischemic Stroke and Transient Ischemic Attack: A Cluster Randomized Clinical Trial. JAMA Neurol 2019; 76:932-941. [PMID: 31058947 DOI: 10.1001/jamaneurol.2019.1012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. Objective To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. Design, Setting and Participants This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. Interventions The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. Main Outcomes and Measures The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). Results A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). Conclusions and Relevance A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. Trial Registration ClinicalTrials.gov identifier: NCT02223273.
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Affiliation(s)
| | | | | | - M Cecilia Bahit
- Fundacion Instituto de Neurología Cognitiva Rosario, Grupo Argentino Colaborativo en Investigación Clínica, Rosario, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ying Xian
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Héquet D, Huchon C, Soilly AL, Asselain B, Berseneff H, Trichot C, Combes A, Alves K, Nguyen T, Rouzier R, Baffert S. Direct medical and non-medical costs of a one-year care pathway for early operable breast cancer: Results of a French multicenter prospective study. PLoS One 2019; 14:e0210917. [PMID: 31291250 PMCID: PMC6619952 DOI: 10.1371/journal.pone.0210917] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 06/07/2019] [Indexed: 01/12/2023] Open
Abstract
Introduction The organization of health care for breast cancer (BC) constitutes a public health challenge to ensure quality of care, while also controlling expenditure. Few studies have assessed the global care pathway of early BC patients, including a description of direct medical costs and their determinants. The aims of this multicenter prospective study were to describe care pathways of BC patients in a geographic territory and to calculate the global direct costs of early stage BC during the first year following diagnosis. Methods OPTISOINS01 was a multicenter, prospective, observational study including early BC patients from diagnosis to one-year follow-up. Direct medical costs (in-hospital and out-of-hospital costs, supportive care costs) and direct non-medical costs (transportation and sick leave costs) were calculated by using a cost-of-illness analysis based on a bottom-up approach. Resources consumed were recorded in situ for each patient, using a prospective direct observation method. Results Data from 604 patients were analyzed. Median direct medical costs of 1 year of management after diagnosis in operable BC patients were €12,250. Factors independently associated with higher direct medical costs were: diagnosis on the basis of clinical signs, invasive cancer, lymph node involvement and conventional hospitalization for surgery. Median sick leave costs were €8,841 per patient and per year. Chemotherapy was an independent determinant of sick leave costs (€3,687/patient/year without chemotherapy versus €10,706 with chemotherapy). Forty percent (n = 242) of patients declared additional personal expenditure of €614/patient/year. No drivers of these costs were identified. Conclusion Initial stage of disease and the treatments administered were the main drivers of direct medical costs. Direct non-medical costs essentially consisted of sick leave costs, accounting for one-half of direct medical costs for working patients. Out-of-pocket expenditure had a limited impact on the household.
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Affiliation(s)
- Delphine Héquet
- Department of Surgical Oncology, Institut Curie, St Cloud, France
- * E-mail:
| | - Cyrille Huchon
- Department of Gynecology, Poissy-St Germain hospital, Poissy, France
| | - Anne-Laure Soilly
- Health Economics Department, CHU Dijon Bourgogne, Délégation à la Recherche Clinique et à l’Innovation, USMR, Dijon, France
| | | | | | - Caroline Trichot
- Department of Gynecology, Antoine Béclère Hospital, Clamart, France
| | - Aline Combes
- Department of Gynecology, André Mignot Hospital, Versailles, France
| | - Karine Alves
- Department of Gynecology, Argenteuil Hospital, Argenteuil, France
| | - Thuy Nguyen
- Department of Gynecology, Louis Mourier Hospital, Colombes, France
| | - Roman Rouzier
- Department of Surgical Oncology, Institut Curie, St Cloud, France
| | - Sandrine Baffert
- Health Economics Department, Institut Curie, Paris, France/CEMKA-EVAL, Bourg-La-Reine, France
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Bird ML, Miller T, Connell LA, Eng JJ. Moving stroke rehabilitation evidence into practice: a systematic review of randomized controlled trials. Clin Rehabil 2019; 33:1586-1595. [PMID: 31066289 DOI: 10.1177/0269215519847253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the effectiveness of interventions aimed at moving research evidence into stroke rehabilitation practice through changing the practice of clinicians. DATA SOURCES EMBASE, CINAHL, Cochrane and MEDLINE databases were searched from 1980 to April 2019. International trial registries and reference lists of included studies completed our search. REVIEW METHODS Randomized controlled trials that involved interventions aiming to change the practice of clinicians working in stroke rehabilitation were included. Bias was evaluated using RevMan to generate a risk of bias table. Evidence quality was evaluated using GRADE criteria. RESULTS A total of 16 trials were included (250 sites, 14,689 patients), evaluating a range of interventions including facilitation, audit and feedback, education and reminders. Of which, 11 studies included multicomponent interventions (using a combination of interventions). Four used educational interventions alone, and one used electronic reminders. Risk of bias was generally low. Overall, the GRADE criteria indicated that this body of literature was of low quality. This review found higher efficacy of trials which targeted fewer outcomes. Subgroup analysis indicated moderate-level GRADE evidence (103 sites, 10,877 patients) that trials which included both site facilitation and tailoring for local factors were effective in changing clinical practice. The effect size of these varied (odds ratio: 1.63-4.9). Education interventions alone were not effective. CONCLUSION A large range of interventions are used to facilitate clinical practice change. Education is commonly used, but in isolation is not effective. Multicomponent interventions including facilitation and tailoring to local settings can change clinical practice and are more effective when targeting fewer changes.
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Affiliation(s)
| | - Tiev Miller
- Hong Kong Polytechnic University, Hong Kong, China
| | | | - Janice J Eng
- University of British Columbia, Vancouver, BC, Canada
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11
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Koolen EH, van der Wees PJ, Westert GP, Dekhuijzen R, Heijdra YF, van 't Hul AJ. The COPDnet integrated care model. Int J Chron Obstruct Pulmon Dis 2018; 13:2225-2235. [PMID: 30050295 PMCID: PMC6056161 DOI: 10.2147/copd.s150820] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Introduction This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options. Theory and methods The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems. Results An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care. Discussion In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care. Conclusion Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.
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Affiliation(s)
- Eleonore H Koolen
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Philip J van der Wees
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Richard Dekhuijzen
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Yvonne F Heijdra
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
| | - Alex J van 't Hul
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands,
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12
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Wang Y, Li Z, Zhao X, Wang C, Wang X, Wang D, Liang L, Liu L, Wang C, Li H, Shen H, Bettger J, Pan Y, Jiang Y, Yang X, Zhang C, Han X, Meng X, Yang X, Kang H, Yuan W, Fonarow GC, Peterson ED, Schwamm LH, Xian Y, Wang Y. Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China: A Randomized Clinical Trial. JAMA 2018; 320:245-254. [PMID: 29959443 DOI: 10.1001/jama.2018.8802] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. OBJECTIVE To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. DESIGN, SETTING, AND PARTICIPANTS A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. INTERVENTIONS Twenty hospitals received a multifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). MAIN OUTCOMES AND MEASURES The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. RESULTS Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, -0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, -2.03% [95% CI, -3.51% to -0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, -2.18% [95% CI, -4.0% to -0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, -3.13% [95% CI, -5.28% to -0.97%]; P = .005). CONCLUSIONS AND RELEVANCE Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02212912.
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Affiliation(s)
- Yilong Wang
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xingquan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Chunjuan Wang
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xianwei Wang
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Illinois Neurological Institute Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, Peoria
| | - Li Liang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Liping Liu
- Neuro-intensive Care Unit, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunxue Wang
- Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Haipeng Shen
- Faculty of Business and Economics, University of Hong Kong, Hong Kong, China
| | - Janet Bettger
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Yuesong Pan
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaomeng Yang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Changqing Zhang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiujie Han
- Department of Neurology, Anshanshi Changda Hospital, Liaoning, China
| | - Xia Meng
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin Yang
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hong Kang
- Department of Neurology, General Hospital of Benxi Iron and Steel, Liaoning, China
| | - Weiqiang Yuan
- Department of Neurology, People's of the Fifth Hospital of Hengshui City, Hebei, China
| | - Gregg C Fonarow
- Ahmanson/University of California, Los Angeles (UCLA), Cardiomyopathy Center, Ronald Reagan UCLA Medical Center
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Yongjun Wang
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Mason C, Ellis PG, Lokay K, Barry A, Dickson N, Page R, Polite B, Salgia R, Savin M, Shamah C, Socinski MA. Patterns of Biomarker Testing Rates and Appropriate Use of Targeted Therapy in the First-Line, Metastatic Non-Small Cell Lung Cancer Treatment Setting. JOURNAL OF CLINICAL PATHWAYS : THE FOUNDATION OF VALUE-BASED CARE 2018; 4:49-54. [PMID: 31453358 PMCID: PMC6709712 DOI: 10.25270/jcp.2018.02.00001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite clear clinical benefit and guideline recommendations for predictive biomarker testing and subsequent first-line targeted therapy treatment in patients with non-small cell lung cancer (NSCLC), there is evidence that testing has not been widely embraced in the clinical setting. This study uses clinical pathways to understand biomarker testing patterns and ensuing first-line treatment decisions. Data of patients with metastatic NSCLC were analyzed for testing rates and treatment selection at 7 cancer programs using data input by providers into the pathways software. Findings were analyzed by type of provider (community or academic). Among providers using clinical pathways, biomarker testing rates were high and appropriate selection of targeted therapy was observed. Clinical pathways can act as a tool to assist oncology practices to promote testing of key biomarkers and subsequent selection of appropriate therapy.
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Affiliation(s)
- Casey Mason
- Florida State University College of Medicine, Tallahassee, FL
| | | | | | | | | | - Ray Page
- The Center for Cancer and Blood Disorders, Fort Worth, TX
| | | | - Ravi Salgia
- City of Hope Comprehensive Cancer Center, Duarte, CA
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Allanson ER, Tunçalp Ö, Vogel JP, Khan DN, Oladapo OT, Long Q, Gülmezoglu AM. Implementation of effective practices in health facilities: a systematic review of cluster randomised trials. BMJ Glob Health 2017; 2:e000266. [PMID: 29081997 PMCID: PMC5656132 DOI: 10.1136/bmjgh-2016-000266] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/16/2017] [Accepted: 06/05/2017] [Indexed: 11/08/2022] Open
Abstract
Background The capacity for health systems to support the translation of research in to clinical practice may be limited. The cluster randomised controlled trial (cluster RCT) design is often employed in evaluating the effectiveness of implementation of evidence-based practices. We aimed to systematically review available evidence to identify and evaluate the components in the implementation process at the facility level using cluster RCT designs. Methods All cluster RCTs where the healthcare facility was the unit of randomisation, published or written from 1990 to 2014, were assessed. Included studies were analysed for the components of implementation interventions employed in each. Through iterative mapping and analysis, we synthesised a master list of components used and summarised the effects of different combinations of interventions on practices. Results Forty-six studies met the inclusion criteria and covered the specialty groups of obstetrics and gynaecology (n=9), paediatrics and neonatology (n=4), intensive care (n=4), internal medicine (n=20), and anaesthetics and surgery (n=3). Six studies included interventions that were delivered across specialties. Nine components of multifaceted implementation interventions were identified: leadership, barrier identification, tailoring to the context, patient involvement, communication, education, supportive supervision, provision of resources, and audit and feedback. The four main components that were most commonly used were education (n=42, 91%), audit and feedback (n=26, 57%), provision of resources (n=23, 50%) and leadership (n=21, 46%). Conclusions Future implementation research should focus on better reporting of multifaceted approaches, incorporating sets of components that facilitate the translation of research into practice, and should employ rigorous monitoring and evaluation.
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Affiliation(s)
- Emma R Allanson
- School of Women's and Infants' Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Crawley, Australia.,Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Joshua P Vogel
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Dina N Khan
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Qian Long
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Ahmet Metin Gülmezoglu
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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15
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Robertson-Preidler J, Biller-Andorno N, Johnson TJ. What is appropriate care? An integrative review of emerging themes in the literature. BMC Health Serv Res 2017; 17:452. [PMID: 28666438 PMCID: PMC5493089 DOI: 10.1186/s12913-017-2357-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 06/06/2017] [Indexed: 01/16/2023] Open
Abstract
Background Health care improvement efforts should be aligned in order to make a meaningful impact on health systems. Appropriate care delivery could be a unifying goal to help coordinate efforts to improve health outcomes and ensure system sustainability. A more complete understanding of how appropriate care is currently conceived in research and clinical practice could help inform a more integrated and holistic concept of appropriate care that could guide health care policy and delivery practices. We examined the current understanding of appropriate care by identifying its use and definitions in recently published literature. Methods An integrated review of the practices, goals and perspectives of appropriate care in English language peer-reviewed articles published from 2011 to 2016. Inductive content analysis was used to describe emerging themes of appropriate care in articles meeting inclusion criteria. Results This integrative review included empirical studies, reviews, and commentaries with various health care settings, cultural contexts, and perspectives. Conceptualizations of appropriate care varied, however most descriptions fell into five main categories: evidence-based care, clinical expertise, patient-centeredness, resource use, and equity. These categories were often used in combination, indicating an integrated understanding of appropriate care. Conclusions An understanding of how appropriate care is conceptualized in research and policy can help inform an integrated approach to appropriate care delivery in policy and practice according to the relevant priorities and circumstances.
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Affiliation(s)
- Joelle Robertson-Preidler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zürich, Switzerland.
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zürich, Switzerland
| | - Tricia J Johnson
- Department of Health Systems Management, Rush University, 1700 W. Van Buren Street, Suite 126B, Chicago, IL, 60612, USA
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16
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Panella M, Rinaldi C, Leigheb F, Knesse S, Donnarumma C, Kul S, Vanhaecht K, Di Stanislao F. Prevalence and costs of defensive medicine: a national survey of Italian physicians. J Health Serv Res Policy 2017; 22:211-217. [PMID: 28534429 DOI: 10.1177/1355819617707224] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To identify the prevalence of the practice of defensive medicine among Italian hospital physicians, its costs and the reasons for practising defensive medicine and possible solutions to reduce the practice of defensive medicine. Methods Cross-sectional web survey. Main outcome measures Number of physicians reporting having engaged in any defensive medicine behaviour in the previous year. Results A total of 1313 physicians completed the survey. Ninety-five per cent believed that defensive medicine would increase in the near future. The practice of defensive medicine accounted for approximately 10% of total annual Italian national health expenditure. Conclusions Defensive medicine is a significant factor in health care costs without adding any benefit to patients. The economic burden of defensive medicine on health care systems should provide a substantial stimulus for a prompt review of this situation in a time of economic crisis. Malpractice reform, together with a systematic use of evidence-based clinical guidelines, is likely to be the most effective way to reduce defensive medicine.
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Affiliation(s)
- Massimiliano Panella
- 1 Associate Professor, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Carmela Rinaldi
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Fabrizio Leigheb
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Sanita Knesse
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Chiara Donnarumma
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Seval Kul
- 3 Associate Professor, School of Medicine, Department of Biostatistics, University of Gaziantep, Turkey
| | - Kris Vanhaecht
- 4 Assistant Professor, Leuven Institute for Healthcare Policy, KU Leuven, University of Leuven, Belgium
| | - Francesco Di Stanislao
- 5 Professor, Biomedical Sciences and Public Health, Universita' Politecnica delle Marche, Ancona, Italy
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17
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Ellis PG, O'Neil BH, Earle MF, McCutcheon S, Benson H, Krebs M, Lokay K, Barry A. Clinical Pathways: Management of Quality and Cost in Oncology Networks in the Metastatic Colorectal Cancer Setting. J Oncol Pract 2017; 13:e522-e529. [PMID: 28379722 DOI: 10.1200/jop.2016.019232] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Via Pathways (clinical pathways for cancer) provide evidence-based guidance for specific patient presentations based on the merit of efficacy, then toxicity, and finally cost (if efficacy and toxicity are comparable). We evaluated the impact of a change to the guidance in the metastatic colorectal cancer (mCRC) setting across two large, integrated health networks. METHODS Cetuximab and panitumumab were determined to have equal efficacy in the treatment of mCRC with no significant difference in toxicity based on recent data from key clinical studies. A cost analysis using Centers for Medicare and Medicaid Services average sales data determined a cost advantage for panitumumab. A substitution of panitumumab for cetuximab in the clinical pathway for all mCRC lines of therapy was initiated as of August 2014. RESULTS In the preimplementation period, 86 (93.5%) and six (6.5%) treatment selections were for cetuximab and panitumumab, respectively. After the pathway change was implemented, 13 (18.1%) and 59 (81.9%) treatment selections were for cetuximab and panitumumab, respectively. The change in prescribing habits was rapidly altered by the pathway change. The estimated annualized cost savings for the two health networks resulting from the response to the pathway change was $711,021. CONCLUSION This study demonstrates that clinical pathways can act as a tool to assist oncology practices in decreasing costs and quickly responding to changing treatment paradigms by providing clinicians with consensus-driven treatment recommendations that incorporate the most up-to-date clinical trial results, toxicity considerations, and regimen cost information.
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Affiliation(s)
- Peter G Ellis
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Bert H O'Neil
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Martin F Earle
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Stephanie McCutcheon
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Hans Benson
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Melinda Krebs
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Kathy Lokay
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
| | - Amanda Barry
- University of Pittsburgh Medical Center Cancer Center; Via Oncology, Pittsburgh, PA; and Indiana University Health, Indianapolis, IN
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Vanclooster A, Wollersheim H, Vanhaecht K, Swinkels D, Aertgeerts B, Cassiman D. Key-interventions derived from three evidence based guidelines for management and follow-up of patients with HFE haemochromatosis. BMC Health Serv Res 2016; 16:573. [PMID: 27733158 PMCID: PMC5062877 DOI: 10.1186/s12913-016-1835-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/08/2016] [Indexed: 01/20/2023] Open
Abstract
Background HFE-related hereditary haemochromatosis (HH) is a common autosomal recessive disorder with clinical manifestations ranging from asymptomatic disease to possible life-threatening complications. Cirrhosis, hepatocellular carcinoma, diabetes mellitus or osteoporosis can develop in HH patients not treated or monitored optimally. The purpose of this study was to develop key-interventions (KI’s) to measure and improve the quality of care delivered to patients diagnosed with HH. Methods A RAND-Modified Delphi method was used to develop KI’s. In the first round of a scoring form to prioritize the recommendations extracted from evidence-based guidelines was circulated between experts. The results of this survey were discussed in a consensus meeting, followed by a final appraisal of the selected recommendations. This resulted in a list of measurable KI’s. Results Initially, 41 key recommendations on screening, diagnosis and treatment/management were extracted from three existing guidelines on HH (European Association for the Study of the Liver, American Association for the Study of Liver Diseases and Dutch guideline on HH). Finally, a core set of 24 recommendations resulted in 15 KI’s. Conclusions This manuscript presents the results of the process to develop KI’s to measure and improve the quality of care for patients with HH. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1835-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annick Vanclooster
- Department of Hepatology and Metabolic Center, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.
| | - Hub Wollersheim
- Scientific Institute for Quality of Healthcare, Nijmegen Centre for Evidence Based Practice, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kris Vanhaecht
- Department of Public Health and Primary Care, Health Services Research Group, KU Leuven, Leuven, Belgium
| | - Dorine Swinkels
- Department of Laboratory Medicine, Laboratory of Genetic Endocrine and Metabolic diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bert Aertgeerts
- Academic Center for General Practice, KU Leuven, Leuven, Belgium
| | - David Cassiman
- Department of Hepatology and Metabolic Center, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
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Husebø SE, Akerjordet K. Quantitative systematic review of multi-professional teamwork and leadership training to optimize patient outcomes in acute hospital settings. J Adv Nurs 2016; 72:2980-3000. [DOI: 10.1111/jan.13035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Sissel Eikeland Husebø
- Department of Health Studies; Faculty of Social Sciences; University of Stavanger; Norway
- Department of Surgery; Stavanger University Hospital; Stavanger Norway
| | - Kristin Akerjordet
- Department of Health Studies; Faculty of Social Sciences; University of Stavanger; Norway
- School of Psychology; University of Wollongong; NSW Australia
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Zhao M, Yan Y, Yang N, Wang X, Tan F, Li J, Li X, Li G, Li J, Zhao Y, Cai Y. Evaluation of clinical pathway in acute ischemic stroke: A comparative study. Eur J Integr Med 2016. [DOI: 10.1016/j.eujim.2015.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Evaluating the effect of clinical care pathways on quality of cancer care: analysis of breast, colon and rectal cancer pathways. J Cancer Res Clin Oncol 2016; 142:1079-89. [PMID: 26762849 DOI: 10.1007/s00432-015-2106-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/27/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Substantial gaps exist between clinical practice and evidence-based cancer care, potentially leading to adverse clinical outcomes and decreased quality of life for cancer patients. This study aimed to evaluate the usefulness of clinical pathways as a tool for improving quality of cancer care, using breast, colon, and rectal cancer pathways as demonstrations. METHODS Newly diagnosed patients with invasive breast, colon, and rectal cancer were enrolled as pre-pathway groups, while patients with the same diagnoses treated according to clinical pathways were recruited for post-pathway groups. RESULTS Compliance with preoperative core biopsy or fine-needle aspiration, utilization of sentinel lymph node biopsy, and proportion of patients whose tumor hormone receptor status was stated in pathology report were significantly increased after implementation of clinical pathway for breast cancer. For colon cancer, compliance with two care processes was significantly improved: surgical resection with anastomosis and resection of at least 12 lymph nodes. Regarding rectal cancer, there was a significant increase in compliance with preoperative evaluation of depth of tumor invasion, total mesorectal excision treatment of middle- or low-position rectal cancer, and proportion of patients who had undergone rectal cancer surgery whose pathology report included margin status. Moreover, total length of hospital stay was decreased remarkably for all three cancer types, and postoperative complications remained unchanged following implementation of the clinical pathways. CONCLUSIONS Clinical pathways can improve compliance with standard care by implementing evidence-based quality indicators in daily practice, which could serve as a useful tool for narrowing the gap between clinical practice and evidence-based care.
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Wang S, Zhu X, Zhao X, Lu Y, Yang Z, Qian X, Li W, Ma L, Guo H, Wang J, Wen A. DRUGS System Improving the Effects of Clinical Pathways: A Systematic Study. J Med Syst 2015; 40:59. [DOI: 10.1007/s10916-015-0400-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/04/2015] [Indexed: 11/30/2022]
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Chiu D, Klucznik RP, Turan TN, Lynn MJ, McCane CD, Katz LB, Nizam A, Derdeyn CP, Fiorella D, Lane BF, Montgomery J, Janis S, Chimowitz MI. Enrollment volume effect on risk factor control and outcomes in the SAMMPRIS trial. Neurology 2015; 85:2090-7. [PMID: 26561294 DOI: 10.1212/wnl.0000000000002191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 07/13/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The role of physician experience and patient volumes on the outcome of surgical or endovascular procedures has been well-studied but there are limited data on how these factors affect the outcome of medical therapy. METHODS In the stenting and medical cohorts of the Stenting and Aggressive Medical Management for the Prevention of Recurrent Ischemic Stroke (SAMMPRIS) trial, we compared Kaplan-Meier (K-M) curves for the primary endpoint (any stroke or death within 30 days of enrollment or ischemic stroke in the territory beyond 30 days) using the log-rank test and the percentages of patients achieving target levels for primary and secondary risk factors during the study using Fisher exact test between patients at high-enrolling (≥12 patients) vs low-enrolling (<12 patients) sites. RESULTS In the stenting group, the K-M curves for the primary endpoint were similar at high-enrolling sites and low-enrolling sites (p = 0.93) with rates of 13.5% vs 14.7% at 30 days and 19.0% vs 20.6% at 2 years. In the medical group, the K-M curves differed between high-enrolling sites and low-enrolling sites (p = 0.0005) with rates of 1.8% vs 9.8% at 30 days and 7.3% vs 20.9% at 2 years. The percentages of patients who achieved targets for low-density lipoprotein cholesterol and systolic blood pressure at high- vs low-enrolling sites in both treatment groups combined were 64% vs 49% (p = 0.003) and 70% vs 59% (p = 0.026), respectively. CONCLUSIONS High-enrolling sites in SAMMPRIS achieved better control of primary risk factors and much lower rates of the primary endpoint than low-enrolling sites in the medical group, suggesting that experience with medical management is an important determinant of patient outcome.
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Affiliation(s)
- David Chiu
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD.
| | - Richard P Klucznik
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Tanya N Turan
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Michael J Lynn
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Charles D McCane
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Lawrence B Katz
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Azhar Nizam
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Colin P Derdeyn
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - David Fiorella
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Bethany F Lane
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Jean Montgomery
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Scott Janis
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
| | - Marc I Chimowitz
- From Houston Methodist Hospital (D.C., R.P.K., C.D.M., L.B.K.), Weill Cornell Medical College, TX; Medical University of South Carolina (T.N.T., M.I.C.), Charleston; Emory University Rollins School of Public Health (M.J.L., A.N., B.F.L., J.M.), Atlanta, GA; Washington University School of Medicine (C.P.D.), St Louis, MO; State University of New York (D.F.), Stony Brook; and National Institute of Neurological Disorders and Stroke (S.J.), National Institute of Health, Bethesda, MD
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Katzan IL, Fan Y, Speck M, Morton J, Fromwiller L, Urchek J, Uchino K, Griffith SD, Modic M. Electronic Stroke CarePath. Circ Cardiovasc Qual Outcomes 2015; 8:S179-89. [DOI: 10.1161/circoutcomes.115.001808] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chapman BV, Rajagopalan MS, Heron DE, Flickinger JC, Beriwal S. Clinical Pathways: A Catalyst for the Adoption of Hypofractionation for Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2015; 93:854-61. [PMID: 26530754 DOI: 10.1016/j.ijrobp.2015.08.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/08/2015] [Accepted: 08/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Hypofractionated whole-breast irradiation (HF-WBI) remains underutilized in the United States despite support by multiple clinical trials. We evaluated the success of iterative modifications of our breast cancer clinical pathway on the adoption of HF-WBI in a large, integrated radiation oncology network. METHODS AND MATERIALS The breast clinical pathway was modified in January 2011 (Amendment 1) to recommend HF-WBI as the first option for women ≥70 of age with stages 0 to IIA, while maintaining conventional fractionation (CF) as a pathway-concordant secondary option. In January 2013 (Amendment 2), the pathway's HF-WBI recommendation was extended to women ≥50 years of age. In January 2014 (Amendment 3), the pathway mandated HF-WBI as the only pathway-concordant option in women ≥50 years of age, and all pathway-discordant plans were subject to peer review and justification. Women ≥50 years of age with ductal carcinoma in situ or invasive breast cancer who underwent breast conserving surgery and adjuvant WBI were included in this analysis. RESULTS We identified 5112 patients from 2009 to 2014 who met inclusion criteria. From 2009 to 2012, the overall HF-WBI use rate was 8.3%. Following Amendments 2 and 3 (2013 and 2014, respectively), HF-WBI use significantly increased to 21.8% (17.3% in the community, 39.7% at academic sites) and 76.7% (75.5% in the community, 81.4% at academic sites), respectively (P<.001). Compared to 2009 to 2012, the relative risk of using HF-WBI was 7.9 (95% confidence interval: 7.1-8.6, P<.001) and 10.7 (95% CI: 10.3-11.0, P<.001), respectively, after Amendments 2 and 3, respectively. Age ≥70 and treatment at an academic site increased the likelihood of receiving HF-WBI in 2009 to 2012 and following Amendment 2 (P<.001). CONCLUSIONS This study demonstrates the transformative effect of a clinical pathway on patterns of care for breast radiation therapy. Although our initial HF-WBI use rate was low (8%-22%) and consistent with national rates, the clinical pathway approach dramatically increased adoption rate to >75%. In contrast to passive guidelines, clinical pathways serve as active tools to promote current best practices.
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Affiliation(s)
- Bhavana V Chapman
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Malolan S Rajagopalan
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
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Aeyels D, Van Vugt S, Sinnaeve PR, Panella M, Van Zelm R, Sermeus W, Vanhaecht K. Lack of evidence and standardization in care pathway documents for patients with ST-elevated myocardial infarction. Eur J Cardiovasc Nurs 2015; 15:e45-51. [DOI: 10.1177/1474515115580237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/12/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Daan Aeyels
- Department of Public Health and Primary Care, University of Leuven, Belgium
- European Pathway Association, Belgium
| | - Stijn Van Vugt
- Department of Public Health and Primary Care, University of Leuven, Belgium
| | - Peter R Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium
| | - Massimiliano Panella
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University of Eastern Piedmont, Italy
| | - Ruben Van Zelm
- European Pathway Association, Belgium
- QConsult, The Netherlands
| | - Walter Sermeus
- Department of Public Health and Primary Care, University of Leuven, Belgium
- European Pathway Association, Belgium
| | - Kris Vanhaecht
- Department of Public Health and Primary Care, University of Leuven, Belgium
- European Pathway Association, Belgium
- Department of Quality Management, University Hospitals Leuven, Belgium
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Miani C, Ball S, Pitchforth E, Exley J, King S, Roland M, Fuld J, Nolte E. Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAvailable evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay.ObjectivesThis study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs.Data sourcesWe searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type.MethodsWe conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England.ResultsA total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.LimitationsWe only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review.ConclusionsThe design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economy.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | | | | | | | | | - Martin Roland
- Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Ellen Nolte
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine, London, UK
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Gache K, Leleu H, Nitenberg G, Woimant F, Ferrua M, Minvielle E. Main barriers to effective implementation of stroke care pathways in France: a qualitative study. BMC Health Serv Res 2014; 14:95. [PMID: 24575955 PMCID: PMC3943407 DOI: 10.1186/1472-6963-14-95] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 02/21/2014] [Indexed: 01/19/2023] Open
Abstract
Background Stroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France. Methods We selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals. Results Four main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care. Conclusion Lack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.
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Affiliation(s)
| | | | - Gérard Nitenberg
- Compaq-HPST, Institut de Cancérologie Gustave Roussy, 114 rue Edouard Vaillant, Villejuif 94805, France.
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Chau PH, Tang MWS, Yeung F, Chan TW, Cheng JOY, Woo J. Can short-term residential care for stroke rehabilitation help to reduce the institutionalization of stroke survivors? Clin Interv Aging 2014; 9:283-91. [PMID: 24550670 PMCID: PMC3926706 DOI: 10.2147/cia.s56532] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Stroke survivors may not be receiving optimal rehabilitation as a result of a shortage of hospital resources, and many of them are institutionalized. A rehabilitation program provided in a short-term residential care setting may help to fill the service gap. Objectives The primary objectives of this study were, first, to examine whether there were significant differences in terms of rehabilitation outcomes at 1 year after admission to the rehabilitation program (defined as baseline) between those using short-term residential care (intervention group) and those using usual geriatric day hospital care (control group), and, second, to investigate whether lower 1-year institutionalization rates were observed in the intervention group than in the control group. Participants 155 stroke survivors who completed at least the first follow-up at 4 months after baseline. Intervention The intervention group was stroke survivors using self-financed short-term residential care for stroke rehabilitation. The control group was stroke survivors using the usual care at a public geriatric day hospital. Measurements Assessments were conducted by trained research assistants using structured questionnaires at baseline, 4 months, and 1 year after baseline. The primary outcome measures included Modified Barthel Index score, Mini-Mental Status Examination score, and the institutionalization rate. Results Cognitive status (as measured by Mini-Mental Status Examination score) of patients in both groups could be maintained from 4 months to 1 year, whereas functional status (as measured by Modified Barthel Index score) of the patients could be further improved after 4 months up to 1 year. Meanwhile, insignificant between-group difference in rehabilitation outcomes was observed. The intervention participants had a significantly lower 1-year institutionalization rate (15.8%) than the control group (25.8%). Conclusion Short-term residential care for stroke rehabilitation promoted improvements in rehabilitation outcomes comparable with, if not better than, the usual care at geriatric day hospital. Furthermore, it had a significantly lower 1-year institutionalization rate. This type of service could be promoted to prevent institutionalization.
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Affiliation(s)
- Pui Hing Chau
- School of Nursing, University of Hong Kong, Hong Kong, Special Administrative Region of the People's Republic of China
| | - Maria W S Tang
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Special Administrative Region of the People's Republic of China
| | - Fannie Yeung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Special Administrative Region of the People's Republic of China
| | - Tsz Wai Chan
- School of Nursing, University of Hong Kong, Hong Kong, Special Administrative Region of the People's Republic of China
| | - Joanna O Y Cheng
- School of Nursing, University of Hong Kong, Hong Kong, Special Administrative Region of the People's Republic of China
| | - Jean Woo
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Special Administrative Region of the People's Republic of China
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Modeling of in-hospital treatment outcomes for elderly patients with heart failure: Care pathway versus usual care. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2012.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Better Interprofessional Teamwork, Higher Level of Organized Care, and Lower Risk of Burnout in Acute Health Care Teams Using Care Pathways. Med Care 2013; 51:99-107. [DOI: 10.1097/mlr.0b013e3182763312] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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