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Zurynski Y, Ludlow K, Testa L, Augustsson H, Herkes-Deane J, Hutchinson K, Lamprell G, McPherson E, Carrigan A, Ellis LA, Dharmayani PNA, Smith CL, Richardson L, Dammery G, Singh N, Braithwaite J. Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review. Implement Sci 2023; 18:62. [PMID: 37957669 PMCID: PMC10641997 DOI: 10.1186/s13012-023-01315-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/08/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. DATA SOURCES AND STUDY SETTING Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. STUDY DESIGN A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool. DATA COLLECTION/EXTRACTION METHODS A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. RESULTS Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. CONCLUSIONS This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area. TRIAL REGISTRATION https://bmjopen.bmj.com/content/7/11/e018568 .
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Affiliation(s)
- Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109.
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia.
| | - Kristiana Ludlow
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Luke Testa
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Hanna Augustsson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden
| | - Jessica Herkes-Deane
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Karen Hutchinson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Gina Lamprell
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Elise McPherson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Ann Carrigan
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Putu Novi Arfirsta Dharmayani
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Carolynn L Smith
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Lieke Richardson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Genevieve Dammery
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Nehal Singh
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
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Marshall DA, Bischak DP, Zaerpour F, Sharif B, Smith C, Reczek T, Robert J, Werle J, Dick D. Wait time management strategies at centralized intake system for hip and knee replacement surgery: A need for a blended evidence-based and patient-centered approach. OSTEOARTHRITIS AND CARTILAGE OPEN 2022; 4:100314. [DOI: 10.1016/j.ocarto.2022.100314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
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Flynn R, Stevens B, Bains A, Kennedy M, Scott SD. Identifying existing approaches used to evaluate the sustainability of evidence-based interventions in healthcare: an integrative review. Syst Rev 2022; 11:221. [PMID: 36243760 PMCID: PMC9569065 DOI: 10.1186/s13643-022-02093-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited evidence to evaluate the sustainability of evidence-based interventions (EBIs) for healthcare improvement. Through an integrative review, we aimed to identify approaches to evaluate the sustainability of evidence-based interventions (EBIs) and sustainability outcomes. METHODS Following Whittemore and Knafl's methodological process: (1) problem identification; (2) literature search; (3) data evaluation; (4) data analysis; and (5) presentation, a comprehensive search strategy was applied across five databases. Included studies were not restricted by research design; and had to evaluate the sustainability of an EBI in a healthcare context. We assessed the methodological quality of studies using the Mixed Methods Appraisal Tool. RESULTS Of 18,783 articles retrieved, 64 fit the inclusion criteria. Qualitative designs were most commonly used for evaluation (48%), with individual interviews as the predominant data collection method. Timing of data collection varied widely with post-intervention data collection most frequent (89%). Of the 64 studies, 44% used a framework, 26% used a model, 11% used a tool, 5% used an instrument, and 14% used theory as their primary approach to evaluate sustainability. Most studies (77%) did not measure sustainability outcomes, rather these studies focused on sustainability determinants. DISCUSSION It is unclear which approach/approaches are most effective for evaluating sustainability and what measures and outcomes are most commonly used. There is a disconnect between evaluating the factors that may shape sustainability and the outcomes approaches employed to measure sustainability. Our review offers methodological recommendations for sustainability evaluation research and highlights the importance in understanding mechanisms of sustainability to advance the field.
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Affiliation(s)
- Rachel Flynn
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Bonnie Stevens
- Lawrence S Bloomberg Faculty of Nursing and Faculties of Medicine and Dentistry, University of Toronto, Toronto, Canada.,Associate Chief Nursing Research & Senior Scientist, Research Institute, The Hospital for Sick Children, 686 Bay St., Toronto, ON, M5G 0A4, Canada
| | - Arjun Bains
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Megan Kennedy
- John W. Scott Health Sciences Library, 2K312 WMC University of Alberta, Edmonton, AB, T6G 2R7, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Fjällström P, Coe AB, Lilja M, Hajdarevic S. Merging existing practices with new ones: the adjustment of organizational routines to using cancer patient pathways in primary healthcare. BMC Health Serv Res 2022; 22:3. [PMID: 34974839 PMCID: PMC8722337 DOI: 10.1186/s12913-021-07348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/29/2021] [Indexed: 12/05/2022] Open
Abstract
Background The introduction of new tools can bring unintended consequences for organizational routines. Cancer Patient Pathways (CPP) were introduced into the Swedish healthcare system in 2015 to shorten time to diagnosis and treatment. Primary healthcare (PHC) plays a central role since cancer diagnosis often begins in PHC units. Our study aimed to understand how PHC units adjusted organizational routines to utilizing CPPs. Method Six PHC units of varied size from both urban and rural areas in northern Sweden were included. Grounded theory method was used to collect and analyse group interviews at each unit. Nine group interviews with nurses and physicians, for a total of 41 participants, were performed between March and November 2019. The interviews focused on CPPs as tools, the PHC units’ routines and providers’ experiences with using CPPs in their daily work. Results Our analysis captured how PHC units adjusted organizational routines to utilizing CPPs by fusing existing practices with new practices to offer better quality of care. Specifically, three overarching organizational routines within the PHC units were identified. First, Manoeuvring diverse patient needs with easier patient flow, the PHC units handled the diverse needs of the population while simultaneously drawing upon CPPs to ease the patient flow within the healthcare system. Second, (Dis) integrating internal know-how, the PHC units drew upon internal competence even when PHC know-how was not taken into account by those driving the CPP initiative. Third, Coping with unequal relationships toward secondary care, the PHC units dealt with being in an unequal position while adopting CPPs instead further decreased possibilities to influence decision-making between care-levels. Conclusion Adopting CPPs as a tool within PHC units brought various unintended consequences in organizational routines. Our study from northern Sweden illustrates that the PHC know-how needs to be integrated into the healthcare system to improve the use of new tools as CPP. Further, the relationships between different levels of care should be taken in account when introducing new tools for healthcare. Also, when adopting innovations, unintended consequences need to be further explored empirically in diverse healthcare contexts internationally in order to generate deeper knowledge in the research area.
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Affiliation(s)
| | - Anna-Britt Coe
- Department of Sociology, Umeå University, SE-901 87, Umeå, Sweden
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, SE-901 87, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, SE-901 87, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, SE-901 87, Umeå, Sweden
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Spagnolo J, Breton M, Sasseville M, Sauvé C, Clément JF, Fleet R, Tremblay MC, Rodrigue C, Lebel C, Beauséjour M. Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec. BMC Health Serv Res 2021; 21:1345. [PMID: 34915871 PMCID: PMC8674406 DOI: 10.1186/s12913-021-07286-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/09/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences. METHODS We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation. RESULTS Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability. INTERPRETATION Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.
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Affiliation(s)
- Jessica Spagnolo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 150, Place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada.,Centre de recherche Charles-LeMoyne, Université de Sherbrooke - Campus Longueuil, 150, place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada
| | - Mylaine Breton
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 150, Place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada.,Centre de recherche Charles-LeMoyne, Université de Sherbrooke - Campus Longueuil, 150, place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada
| | - Martin Sasseville
- Centre de recherche Charles-LeMoyne, Université de Sherbrooke - Campus Longueuil, 150, place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada
| | - Carine Sauvé
- Centre intégré de santé et de services sociaux (CISSS) de la Montérégie-Centre, 3141 Boulevard Taschereau Bureau 220, Greenfield Park, QC, J4V 2H2, Canada
| | - Jean-François Clément
- Centre de recherche Charles-LeMoyne, Université de Sherbrooke - Campus Longueuil, 150, place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada.,Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada
| | - Richard Fleet
- Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050, Avenue de la Médecine, Québec, QC, G1V 0A6, Canada.,Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Pavillon Landry-Poulin, 2525 chemin de la Canardière, Québec, QC, G1J 0A4, Canada
| | - Marie-Claude Tremblay
- Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050, Avenue de la Médecine, Québec, QC, G1V 0A6, Canada.,Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Pavillon Landry-Poulin, 2525 chemin de la Canardière, Québec, QC, G1J 0A4, Canada
| | - Cloé Rodrigue
- Centre de recherche Charles-LeMoyne, Université de Sherbrooke - Campus Longueuil, 150, place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada.,Centre intégré de santé et de services sociaux (CISSS) de la Montérégie-Centre, 3141 Boulevard Taschereau Bureau 220, Greenfield Park, QC, J4V 2H2, Canada
| | - Camille Lebel
- Department of Surgery, Faculty of Medicine, Université de Montréal, C.P, 6128, succursale Centre-ville, Montréal, QC, H3C 3J7, Canada
| | - Marie Beauséjour
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 150, Place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada. .,Centre de recherche Charles-LeMoyne, Université de Sherbrooke - Campus Longueuil, 150, place Charles-Le Moyne, C. P. 200, Longueuil, QC, J4K 0A8, Canada. .,Department of Surgery, Faculty of Medicine, Université de Montréal, C.P, 6128, succursale Centre-ville, Montréal, QC, H3C 3J7, Canada.
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Lebedeva Y, Churchill L, Marsh J, MacDonald SJ, Giffin JR, Bryant D. Wait times, resource use and health-related quality of life across the continuum of care for patients referred for total knee replacement surgery. Can J Surg 2021; 64:E253-E264. [PMID: 33908239 PMCID: PMC8327991 DOI: 10.1503/cjs.003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background The escalating socioeconomic burden of knee osteoarthritis (OA) underscores the need for innovative strategies to reduce wait times for total knee arthroplasty (TKA). The purpose of this study was to evaluate resource use, costs and health-related quality of life (HRQoL) across the continuum of care for patients with knee OA. Methods This was a prospective study of 383 patients recruited from a high-volume teaching hospital at different stages of care (referral, consultation and presurgery). Outcomes included health care resource use; costs captured from the health care payer, private sector and societal perspectives; HRQoL measured using the Western Ontario and McMaster Universities Osteoarthritis Index, the 12-Item Short Form Health Survey, and EuroQoL 5-Dimension 5-Level tool; wait times; and the proportion of referrals deemed suitable candidates for surgery. Results The most commonly used conservative treatments were pharmacotherapy, exercise and lifestyle modification. Forty percent of patients referred for TKA were deemed not to be suitable candidates for surgery. The greatest proportion of costs was borne by the patient or private insurer; a small proportion was borne by the public payer. Across all stages of care, more than 60% of the total costs was attributed to productivity losses. HRQoL remained relatively stable throughout the waiting period (mean wait time from referral to TKA 13.2 mo) but improved postoperatively. Conclusion The suboptimal primary care management of knee OA calls for the development of innovative models of care. This study may provide valuable guidance on the design and implementation of a new online educational platform to improve referral efficiency and expedite wait times for TKA.
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Affiliation(s)
- Yekaterina Lebedeva
- Health and Rehabilitation Sciences Program, Western University, London, Ont. (Lebedeva); School of Physical Therapy, Western University, London, Ont. (Churchill, Marsh, Bryant); Fowler Kennedy Sport Medicine Clinic, London, Ont. (Churchill, Giffin); Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (MacDonald, Giffin); University Hospital, London Health Sciences Centre, London, Ont. (MacDonald); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Bryant)
| | - Laura Churchill
- Health and Rehabilitation Sciences Program, Western University, London, Ont. (Lebedeva); School of Physical Therapy, Western University, London, Ont. (Churchill, Marsh, Bryant); Fowler Kennedy Sport Medicine Clinic, London, Ont. (Churchill, Giffin); Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (MacDonald, Giffin); University Hospital, London Health Sciences Centre, London, Ont. (MacDonald); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Bryant)
| | - Jacquelyn Marsh
- Health and Rehabilitation Sciences Program, Western University, London, Ont. (Lebedeva); School of Physical Therapy, Western University, London, Ont. (Churchill, Marsh, Bryant); Fowler Kennedy Sport Medicine Clinic, London, Ont. (Churchill, Giffin); Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (MacDonald, Giffin); University Hospital, London Health Sciences Centre, London, Ont. (MacDonald); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Bryant)
| | - Steven J MacDonald
- Health and Rehabilitation Sciences Program, Western University, London, Ont. (Lebedeva); School of Physical Therapy, Western University, London, Ont. (Churchill, Marsh, Bryant); Fowler Kennedy Sport Medicine Clinic, London, Ont. (Churchill, Giffin); Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (MacDonald, Giffin); University Hospital, London Health Sciences Centre, London, Ont. (MacDonald); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Bryant)
| | - J Robert Giffin
- Health and Rehabilitation Sciences Program, Western University, London, Ont. (Lebedeva); School of Physical Therapy, Western University, London, Ont. (Churchill, Marsh, Bryant); Fowler Kennedy Sport Medicine Clinic, London, Ont. (Churchill, Giffin); Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (MacDonald, Giffin); University Hospital, London Health Sciences Centre, London, Ont. (MacDonald); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Bryant)
| | - Dianne Bryant
- Health and Rehabilitation Sciences Program, Western University, London, Ont. (Lebedeva); School of Physical Therapy, Western University, London, Ont. (Churchill, Marsh, Bryant); Fowler Kennedy Sport Medicine Clinic, London, Ont. (Churchill, Giffin); Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (MacDonald, Giffin); University Hospital, London Health Sciences Centre, London, Ont. (MacDonald); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont. (Bryant)
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Bobman J, Mayfield CK, Bolia IK, Kang HP, Hinckel BB, Gipsman A, Hatch GFR, Heckmann N, Weber AE. Conversion rates and timing to total knee arthroplasty following anterior cruciate ligament reconstruction: a US population-based study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:353-362. [PMID: 33893545 DOI: 10.1007/s00590-021-02966-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/29/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE To define the rate of subsequent TKA following ACLR in a large US cohort and to identify factors that influence the risk of later undergoing TKA after ACLR. METHODS The California's Office of Statewide Health Planning and Development (OSHPD) database was queried from 2000 to 2014 to identify patients who underwent primary ACLR (ACL group). An age-and gender-matched cohort that underwent appendectomy was selected as the control group. The cumulative incidence of TKA was calculated and ten-year survival was investigated using Kaplan-Meier analysis with failure defined as conversion to arthroplasty. Univariate and multivariate analyses were performed to explore the risk factors for conversion to TKA following ACLR. RESULTS A total of 100,580 ACLR patients (mean age 34.48 years, 66.1%male) were matched to 100,545 patients from the general population. The ACL cohort had 1374 knee arthroplasty events; conversion rate was 0.71% at 2-year follow-up, 2.04% at 5-year follow-up, and 4.86% at 10-year follow-up. This conversion rate was higher than that of the control group at all time points, with an odds ratio of 3.44 (p<0.001) at 10-year follow-up. Decreasing survivorship following ACLR was observed with increasing age, female gender, and worker's compensation insurance, while increased survivorship was found in patients of Hispanic and Asian Pacific Islander racial heritage and those who underwent concomitant meniscal repair. CONCLUSIONS In this US statewide study, the rate of TKA after ACLR is higher than reported elsewhere, with significantly increased odds when compared to a control group. Age, gender, concomitant knee procedures and other socioeconomic factors influence the rate of conversion to TKA following ACLR.
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Affiliation(s)
- Jacob Bobman
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | - Cory K Mayfield
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | - Ioanna K Bolia
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | - Hyunwoo P Kang
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | | | - Aaron Gipsman
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | - George F Rick Hatch
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | - Nathanael Heckmann
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA
| | - Alexander E Weber
- Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA.
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Donovan H, Ellis E, Cole L, Townsend E, Cases A. Reducing time to complete neuropsychological assessments within a memory assessment service and evaluating the wider impact. BMJ Open Qual 2020; 9:bmjoq-2019-000767. [PMID: 32727868 PMCID: PMC7394246 DOI: 10.1136/bmjoq-2019-000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 06/08/2020] [Accepted: 06/24/2020] [Indexed: 11/16/2022] Open
Abstract
In 2016, the Older People’s Mental Health Service (OPMHS) within Bedfordshire and Luton (provided by East London Foundation National Health Service Trust) faced considerable challenges in providing an accessible service for assessment of suspected dementia. Those referred to the Memory Assessment Service (MAS) encountered waiting times exceeding national recommendations. A quality improvement (QI) project was initiated by OPMHS Psychologists within all four multidisciplinary MAS clinics in Bedfordshire and Luton. The project aimed to reduce the time from the date of referral for within-team neuropsychological assessment to finalisation of the report to 6 weeks (42 days) by April 2017. In parallel to the initiative, the wider impact of the QI project was investigated. Through the combination of change ideas tested and implemented, all four MAS clinics were successful in meeting the primary project aim. The combined mean time between referral received by psychology and report finalised reduced by 28.76 days from 65.1 to 36.34 days, and with reduced variation across the clinics. These changes were sustained throughout the duration of the project and beyond, and successful change ideas were incorporated into routine practice with control methods developed. Exploring the wider impact, a focus group with six psychology staff members involved in the project was also completed. Thematic analysis identified three themes from the focus group: staff impact, service impact and service user impact. Further subthemes were identified regarding both desirable and undesirable impact across the system. The approaches used may be useful for other services embarking on reduced wait time initiatives for access to care. Additionally, understanding ongoing areas of impact on staff, the wider service and service users can help reduce or mitigate undesirable or unintended consequences and work towards sustainability of such changes.
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Affiliation(s)
- Helen Donovan
- Bedfordshire and Luton Mental Health Services, East London NHS Foundation Trust, Bedfordshire, UK
| | - Emma Ellis
- Bedfordshire and Luton Mental Health Services, East London NHS Foundation Trust, Bedfordshire, UK
| | - Laura Cole
- Clinical Psychology Doctorate Programme, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Emma Townsend
- Clinical Psychology Doctorate Programme, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, UK
| | - Alejandra Cases
- Slough Older People's Mental Health Service, Berkshire Healthcare NHS Foundation Trust, Slough, UK
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Laberge M, Côté A, Ruiz A. Clinical pathway efficiency for elective joint replacement surgeries: a case study. J Health Organ Manag 2019; 33:323-338. [PMID: 31122119 DOI: 10.1108/jhom-03-2018-0087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation. DESIGN/METHODOLOGY/APPROACH This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory. FINDINGS There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps. RESEARCH LIMITATIONS/IMPLICATIONS The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged. PRACTICAL IMPLICATIONS Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations. SOCIAL IMPLICATIONS Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other. ORIGINALITY/VALUE Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.
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Affiliation(s)
- Maude Laberge
- Department of Operations and Decision Systems, Universite Laval Faculte des sciences de l'administration , Quebec, Canada
| | - André Côté
- Department of Operations and Decision Systems, Universite Laval Faculte des sciences de l'administration , Quebec, Canada
| | - Angel Ruiz
- Department of Operations and Decision Systems, Universite Laval Faculte des sciences de l'administration , Quebec, Canada
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Abstract
The Commonwealth Fund 2017 report ranked Canada's healthcare system low in access to care and last among all 11 counties studied in terms of timeliness of care. While long wait times for certain elective surgical procedures appear to be emblematic of Canadian Medicare, they are not inevitable. Wait times could be improved by focusing on public awareness and measurement of wait times and improving the appropriateness, efficiency (eg, with implementation of single-entry models for surgical referrals and greater use of ambulatory surgery), and productivity of surgical care (eg, by activity-based funding for surgical procedures and by reducing the cost of perioperative care). Ideas on how physician leaders can build on recent accomplishments are provided.
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Affiliation(s)
- David R Urbach
- 1 Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada
- 2 Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- 3 Women's College Hospital Research Institute, Toronto, Ontario, Canada
- 4 Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- 5 Department of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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