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Cheah MH, Lai PSM, Ong T. Views of healthcare professionals regarding barriers and facilitators for a Fracture Liaison Service in Malaysia. PLoS One 2024; 19:e0307919. [PMID: 39058713 PMCID: PMC11280531 DOI: 10.1371/journal.pone.0307919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/13/2024] [Indexed: 07/28/2024] Open
Abstract
This study aimed to explore the views of healthcare professionals regarding the barriers and facilitators for a Fracture Liaison Service (FLS) in Malaysia. The qualitative study was conducted from February to December 2021 at a tertiary hospital in Malaysia. Doctors, nurses, pharmacists, and policymakers were recruited via purposive sampling. Semi-structured in-depth interviews were conducted until thematic saturation was achieved. Data were transcribed verbatim and analysed using thematic analysis. Thirty participants [doctors (n = 13), nurses (n = 8), pharmacists (n = 8), and policymakers (n = 1)] with 2-28 years of working experience were recruited. Three themes emerged: 1) Current delivery of secondary fracture prevention; 2) Importance of secondary fracture prevention, and 3) FLS sustainability. Some participants reported that the current post-hip fracture care was adequate, whilst some expressed concerns about the lack of coordination and continuity of care, especially in non-hip fragility fracture care. Most participants recognised the importance of secondary fracture prevention as fracture begets fracture, highlighting the need for a FLS to address this care gap. However, some were concerned about competing priorities. To ensure the sustainability of a FLS, cost-effectiveness data, support from relevant stakeholders, increased FLS awareness among patients and healthcare professionals, and a FLS coordinator were required. Training and financial incentives may help address the issue of low confidence and encourage the nurses to take on the FLS coordinator role. Overall, all participants believed that there was a need for a FLS to improve the delivery of secondary fracture prevention. Addressing concerns such as lack of confidence among nurses and lack of awareness can help improve FLS sustainability.
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Affiliation(s)
- Min Hui Cheah
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- School of Medical and Life Sciences, Sunway University, Subang Jaya, Malaysia
| | - Terence Ong
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Duamor CT, Hampson K, Lankester F, Lugelo A, Changalucha J, Lushasi KS, Czupryna A, Mpolya E, Kreppel K, Cleaveland S, Wyke S. Integrating a community-based continuous mass dog vaccination delivery strategy into the veterinary system of Tanzania: A process evaluation using normalization process theory. One Health 2023; 17:100575. [PMID: 37332884 PMCID: PMC10272491 DOI: 10.1016/j.onehlt.2023.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023] Open
Abstract
Abstract Sustained vaccination coverage of domestic dog populations can interrupt rabies transmission. However, challenges remain including low dog owner participation, high operational costs associated with current (centralized and annually delivered (pulse)) approaches and high dog population turnover. To address these challenges an alternative (community-based continuous mass dog vaccination (CBC-MDV)) approach was designed. We investigated the potential for successful normalization of CBC-MDV into routine practice within the context of local communities and the veterinary system of Tanzania. Methods In a process evaluation of a pilot implementation of CBC-MDV, we conducted in-depth interviews with implementers and community leaders (n = 24), focus group discussion with implementers and community members (n = 12), and non-participant observation (n = 157 h) of delivery of the intervention components. We analyzed these data thematically drawing on the normalization process theory, to assess factors affecting implementation and integration. Main findings Implementers and community members clearly understood the values and benefits of the CBC-MDV, regarding it as an improvement over the pulse strategy. They had a clear understanding of what was required to enact CBC-MDV and considered their own involvement to be legitimate. The approach fitted well into routine schedules of implementers and the context (infrastructure, skill sets and policy). Implementers and community members positively appraised CBC-MDV in terms of its perceived impact on rabies and recommended its use across the country. Implementers and community members further believed that vaccinating dogs free of charge was critical and made community mobilization easier. However, providing feedback to communities and involving them in evaluating outcomes of vaccination campaigns were reported to have not been done. Local politics was cited as a barrier to collaboration between implementers and community leaders. Conclusion This work suggests that CBC-MDV has the potential to be integrated and sustained in the context of Tanzania. Involving communities in design, delivery and monitoring of CBC-MDV activities could contribute to improving and sustaining its outcomes.
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Affiliation(s)
- Christian Tetteh Duamor
- Department of Global Health and Biomedical Sciences, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute – Tanzania, Ifakara, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Katie Hampson
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Felix Lankester
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, USA
- Global Animal Health Tanzania, Arusha, Tanzania
| | - Ahmed Lugelo
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute – Tanzania, Ifakara, Tanzania
- Global Animal Health Tanzania, Arusha, Tanzania
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Joel Changalucha
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute – Tanzania, Ifakara, Tanzania
- Global Animal Health Tanzania, Arusha, Tanzania
| | - Kennedy Selestin Lushasi
- Department of Global Health and Biomedical Sciences, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute – Tanzania, Ifakara, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Anna Czupryna
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Global Animal Health Tanzania, Arusha, Tanzania
| | - Emmanuel Mpolya
- Department of Global Health and Biomedical Sciences, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Katharina Kreppel
- Department of Global Health and Biomedical Sciences, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sarah Cleaveland
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Sally Wyke
- Institute of Health and Wellbeing, College of Social Sciences, University of Glasgow, Glasgow, UK
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Carter H, Beard D, Harvey A, Leighton P, Moffatt F, Smith B, Webster K, Logan P. Using normalisation process theory for intervention development, implementation and refinement in musculoskeletal and orthopaedic interventions: a qualitative systematic review. Implement Sci Commun 2023; 4:114. [PMID: 37723546 PMCID: PMC10506319 DOI: 10.1186/s43058-023-00499-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/06/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Normalisation process theory (NPT) provides researchers with a set of tools to support the understanding of the implementation, normalisation and sustainment of an intervention in practice. Previous reviews of published research have explored NPT's use in the implementation processes of healthcare interventions. However, its utility in intervention research, specifically in orthopaedic and musculoskeletal interventions, remains unclear. The aim of this review is to explore how NPT (including extended NPT, ENPT) has been used in orthopaedic/musculoskeletal intervention research. METHODS A qualitative systematic review was conducted. Two bibliographic databases (Scopus and Web of Science) and a search engine (Google Scholar) were searched for peer-reviewed journal articles citing key papers outlining the development of NPT, related methods, tools or the web-based toolkit. We included studies of any method, including protocols, and did not exclude based on published language. A data extraction tool was developed, and data were analysed using a framework approach. RESULTS Citation searches, of the 12 key studies, revealed 10,420 citations. Following duplicate removal, title, abstract and full-text screening, 14 papers from 12 studies were included. There were 8 key findings assessed against GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research). Five were of high confidence supporting NPT/ENPT's use in the implementation process for interventions targeting a range of MSK/orthopaedic conditions. NPT/ENPT offers a useful analytical lens to focus attention and consider implementation factors robustly. There is limited evidence for the selection of NPT/ENPT and for the use of the Normalisation Measure Development instrument. Three findings of moderate confidence suggest that coherence is seen as a fundamental initial step in implementation, there is limited evidence that study population limits NPT's utility and the application of ENPT may pose a challenge to researchers. CONCLUSION This review demonstrates NPT's utility in supporting intervention implementation for orthopaedic and musculoskeletal conditions. We have theorised the benefits ENPT offers to intervention development and refinement and recommend future researchers consider its use. We also encourage future researchers to offer clear justification for NPT's use in their methodology. TRIAL REGISTRATION The review protocol is registered with PROSPERO (CRD42022358558).
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Affiliation(s)
- Hayley Carter
- Physiotherapy Outpatients, Level 3, Florence Nightingale Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE1 2QY, UK.
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK.
| | - David Beard
- Surgical Intervention Trials Unit, Botnar Research Centre, NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Alison Harvey
- Physiotherapy Outpatients, Level 3, Florence Nightingale Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE1 2QY, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Fiona Moffatt
- School of Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2HA, UK
| | - Benjamin Smith
- Physiotherapy Outpatients, Level 3, Florence Nightingale Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE1 2QY, UK
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Kate Webster
- Health Sciences 3 Building, La Trobe University, Kingsbury Drive, Bundoora, VIC, 3086, Australia
| | - Pip Logan
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK
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Bennett MJ, Center JR, Perry L. Exploring barriers and opportunities to improve osteoporosis care across the acute-to-primary care interface: a qualitative study. Osteoporos Int 2023:10.1007/s00198-023-06748-0. [PMID: 37093239 DOI: 10.1007/s00198-023-06748-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/05/2023] [Indexed: 04/25/2023]
Abstract
This qualitative study interviewed general practitioners, patients, and FLS clinicians and identified key challenges facing stakeholders seeking to improve post-fracture osteoporosis care. Local policies and care pathways as an initial strategy may address information and service delivery issues across the acute-primary care divide. INTRODUCTION Fracture liaison services (FLS) can be effective for secondary fracture prevention, but long-term adherence to therapies remains suboptimal. Few studies have explored how services manage the transition between tertiary and primary post-fracture care. This study mapped service processes and factors influencing integration of post-clinic care, identifying barriers, supports, and opportunities for seamless healthcare. METHODS Qualitative descriptive study using semi-structured interviews with FLS stakeholders at two metropolitan hospitals in New South Wales (NSW) and surrounding general practices. RESULTS Seven FLS clinicians, 11 general practitioners (GPs), and seven patients were interviewed. Six key themes emerged on the transition of patient care from tertiary to primary care (PC). Interprofessional communication issues and role ambiguity posed threats to seamless care. Delayed, absent, inaccessible, or poor-quality communication frustrated GPs, while FLS clinicians lacked confidence in existing communication systems and desired bidirectional communication with PC. GPs were confident managing osteoporosis, but FLS clinicians had limited confidence that patients would discuss osteoporosis with their GP and that GPs would action recommendations. Effective PC follow-up required a positive GP-patient relationship and that patients perceived a need to engage with PC. Patient understanding of osteoporosis (influenced by patient education, knowledge, beliefs, and health behaviours) affected PC attendance. Limited public awareness of osteoporosis and healthcare policy deficits contributed to care gaps. CONCLUSION Key challenges were identified facing stakeholders seeking to improving post-clinic osteoporosis care. Development and implementation of local, integrated acute-community policies and care pathways as an initial intervention may address information and service delivery issues across the acute-PC divide.
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Affiliation(s)
- Michael J Bennett
- The Garvan Institute of Medical Research, 384 Victoria St, NSW, Darlinghurst, Australia.
- St George and Sutherland Clinical School, UNSW Medicine, Sydney, Australia.
- Prince of Wales Hospital & Community Health Services, NSW, Randwick, Australia.
| | - Jacqueline R Center
- School of Clinical Medicine, Faculty of Medicine and Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
- The Garvan Institute of Medical Research, 384 Victoria St, NSW, Darlinghurst, Australia
| | - Lin Perry
- Faculty of Health, University of Technology Sydney, NSW, Ultimo, Australia
- Prince of Wales Hospital & Community Health Services, NSW, Randwick, Australia
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Okuda R, Osaki M, Saeki Y, Okano T, Tsuda K, Nakamura T, Morio Y, Nagashima H, Hagino H. Effect of coordinator-based osteoporosis intervention on quality of life in patients with fragility fractures: a prospective randomized trial. Osteoporos Int 2022; 33:1445-1455. [PMID: 35195752 DOI: 10.1007/s00198-021-06279-6] [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] [Received: 06/16/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Abstract
UNLABELLED We examined the effects of the coordinator-based intervention on quality of life (QOL) in the aftermath of a fragility fracture, as well as factors predictive of post-fracture QOL. The coordinator-based interventions mitigated the decrease in QOL. Secondary fracture after primary fracture, however, was a significant predictor of lower QOL. PURPOSE This study aimed to determine the effects of the coordinator-based intervention on QOL in the aftermath of a fragility fracture, as well as factors predictive of post-fracture QOL, in an Asian population. METHODS Patients with new fractures in the intervention group received the coordinator-based intervention by a designated nurse certified as a coordinator, within 3 months of injury. QOL was evaluated using the Japanese version of the EuroQol 5 Dimension 5 Level (EQ-5D-5L) scale before the fracture (through patient recollections) and at 0.5, 1, and 2 years after the primary fracture. RESULTS Data for 141 patients were analyzed: 70 in the liaison intervention (LI) group and 71 in the non-LI group. Significant intervention effects on QOL were observed at 6 months after the fracture; the QOL score was 0.079 points higher in the LI group than in the non-LI group (p=0.019). Further, the LI group reported significantly less pain/discomfort at 2 years after the fracture, compared to the non-LI group (p=0.037). In addition, secondary fractures were found to significantly prevent improvement and maintenance of QOL during the recovery period (p=0.015). CONCLUSION Short-term intervention effects were observable 6 months after the primary fracture, with the LI group mitigated the decrease in QOL. Few patients in the LI group reported pain/discomfort 2 years after the fracture, but there is uncertainty regarding its clinical significance. Secondary fracture after initial injury was a significant predictor of lower QOL after a fracture.
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Affiliation(s)
- R Okuda
- School of Health Science, Faculty of Medicine, Tottori University, 86 Nishi-Cho, Yonago, Tottori, 683-8503, Japan.
| | - M Osaki
- Rehabilitation Division, Tottori University Hospital, Yonago, Tottori, Japan
| | - Y Saeki
- Orthopedic Surgery Hospital Ward, Tottori University Hospital, Yonago, Tottori, Japan
| | - T Okano
- Department of Orthopedic Surgery, San-in Rosai Hospital, Yonago, Tottori, Japan
| | - K Tsuda
- Department of Orthopedic Surgery, Saiseikai Sakaiminato General Hospital, Sakaiminato, Tottori, Japan
| | - T Nakamura
- Department of Orthopedic Surgery, Hakuai Hospital, Yonago, Tottori, Japan
| | - Y Morio
- Department of Orthopedic Surgery, Misasa Onsen Hospital, Misasa, Tottori, Japan
| | - H Nagashima
- Department of Orthopedic Surgery, Tottori University, Yonago, Tottori, Japan
| | - H Hagino
- School of Health Science, Faculty of Medicine, Tottori University, 86 Nishi-Cho, Yonago, Tottori, 683-8503, Japan
- Rehabilitation Division, Tottori University Hospital, Yonago, Tottori, Japan
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Schroeder D, Luig T, Finch TL, Beesoon S, Campbell-Scherer DL. Understanding implementation context and social processes through integrating Normalization Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2022; 3:13. [PMID: 35139915 PMCID: PMC8826671 DOI: 10.1186/s43058-022-00264-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For successful implementation of an innovation within a complex adaptive system, we need to understand the ways that implementation processes and their contexts shape each other. To do this, we need to explore the work people do to make sense of an innovation and integrate it into their workflow and the contextual elements that impact implementation. Combining Normalization Process Theory (NPT) with the Consolidated Framework for Implementation Research (CFIR) offers an approach to achieve this. NPT is an implementation process theory that explains how changes in the way people think about and use an innovation occurs, while CFIR is a framework that categorizes and describes contextual determinants across five domains that influence implementation. We demonstrate through a case example from our prior research how we integrated NPT and CFIR to inform the development of the interview guide, coding manual, and analysis of the findings. METHODS In collaboration with our stakeholders, we selected NPT and CFIR to study the implementation process and co-developed an interview guide to elicit responses that would illuminate concepts from both. We conducted, audio-recorded, and transcribed 28 interviews with various professionals involved with the implementation. Based on independent coding of select transcripts and team discussion comparing, clarifying, and crystallizing codes, we developed a coding manual integrating CFIR and NPT constructs. We applied the integrated codes to all interview transcripts. RESULTS Our findings highlight how integrating CFIR domains with NPT mechanisms adds explanatory strength to the analysis of implementation processes, with particular implications for practical strategies to facilitate implementation. Multiple coding across both theoretical frames captured the entanglement of process and context. Integrating NPT and CFIR enriched understandings of how interactions between implementation processes and contextual determinants shaped each other during implementation. CONCLUSION The integration of NPT and CFIR provides guidance to identify and explore complex entangled interactions between agents, processes, and contextual conditions within and beyond organizations to embed innovations into routine practices. Nuanced understandings gained through this approach moves understandings beyond descriptions of determinants to explain how change occurs or not during implementation. Mechanism-based explanations illuminate concrete practical strategies to support implementation.
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Affiliation(s)
- Dawn Schroeder
- Physician Learning Program, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Thea Luig
- Physician Learning Program, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Tracy L Finch
- Department of Nursing, Midwifery & Health, Northumbria University, Newcastle upon Tyne, UK
| | - Sanjay Beesoon
- Surgery Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Denise Lynn Campbell-Scherer
- Office of Lifelong Learning & Physician Learning Program, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada. .,Department of Family Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada. .,Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada.
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van Zelm R, Coeckelberghs E, Sermeus W, Wolthuis A, Bruyneel L, Panella M, Vanhaecht K. A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory. BMC Health Serv Res 2021; 21:11. [PMID: 33397382 PMCID: PMC7784254 DOI: 10.1186/s12913-020-06011-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/10/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Specific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer. METHODS This comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology. RESULTS Data from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians. CONCLUSIONS Overall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process. TRIAL REGISTRATION NCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.
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Affiliation(s)
- R van Zelm
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - E Coeckelberghs
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - W Sermeus
- Depertment of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Wolthuis
- Depertment of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - L Bruyneel
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - M Panella
- Department of Translational Medicine, University of Eastern Piemonte (UPO), Novarra, Italy
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Quality, Academic Policy Advisor, University Hospital Leuven, Leuven, Belgium
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Implementation of a Ponseti Clubfoot Program Decreases Major Surgery: A Quality Improvement Initiative. Pediatr Qual Saf 2020; 5:e362. [PMID: 33575522 PMCID: PMC7870159 DOI: 10.1097/pq9.0000000000000362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/12/2020] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. Clubfoot describes a congenital condition. If untreated, clubfoot can cause long-term functional issues. The Ponseti method is the gold-standard treatment; it emphasizes casting over surgery. We identified a high rate of major recurrence in patients with isolated clubfoot at our institution. We implemented a quality improvement intervention to address the recurrences.
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Lennox L, Linwood-Amor A, Maher L, Reed J. Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review. Health Res Policy Syst 2020; 18:120. [PMID: 33050921 PMCID: PMC7556957 DOI: 10.1186/s12961-020-00601-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Background Numerous models, tools and frameworks have been produced to improve the sustainability of evidence-based interventions. Due to the vast number available, choosing the most appropriate one is increasingly difficult for researchers and practitioners. To understand the value of such approaches, evidence warranting their use is needed. However, there is limited understanding of how sustainability approaches have been used and how they have impacted research or practice. This review aims to consolidate evidence on the application and impact of sustainability approaches in healthcare settings. Methods A systematic scoping review was designed to search for peer-reviewed publications detailing the use of sustainability approaches in practice. A 5-stage framework for scoping reviews directed the search strategy, and quality assessment was performed using the Mixed Method Appraisal Tool. Searches were performed through electronic citation tracking and snowballing of references. Articles were obtained through Web of Science, PubMed and Google Scholar. Six outcome variables for sustainability were explored to ascertain impact of approaches. Results This review includes 68 articles demonstrating the application of sustainability approaches in practice. Results show an increase in the use of sustainability approaches in peer-reviewed studies. Approaches have been applied across a range of healthcare settings, including primary, secondary, tertiary and community healthcare. Approaches are used for five main purposes, namely analysis, evaluation, guidance, assessment and planning. Results outline benefits (e.g. improved conceptualisation of sustainability constructs and improved ability to interpret sustainability data) and challenges (e.g. issues with approach constructs and difficulty in application) associated with using a sustainability approach in practice. Few articles (14/68) reported the sustainability outcome variables explored; therefore, the impact of approaches on sustainability remains unclear. Additional sustainability outcome variables reported in retrieved articles are discussed. Conclusions This review provides practitioners and researchers with a consolidated evidence base on sustainability approaches. Findings highlight the remaining gaps in the literature and emphasise the need for improved rigour and reporting of sustainability approaches in research studies. To guide future assessment and study of sustainability in healthcare settings an updated list of sustainability outcome variables is proposed. Trial Registration This review was registered on the PROSPERO database CRD 42016040081 in June 2016.
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Affiliation(s)
- L Lennox
- National Institute for Health Research, Applied Research Collaboration North West London. Imperial College London, 369 Fulham Road, SW10 9NH, London, United Kingdom.
| | - A Linwood-Amor
- Ministry of Health, Environment, Culture and Housing, George Town, Grand Cayman KY1-9000, Cayman Islands
| | - L Maher
- Ko Awatea Health System Innovation and Improvement, Middlemore Hospital, 100 Hospital Road, Otahuhu, New Zealand
| | - J Reed
- Julie Reed Consultancy, 27 Molasses House, London, SW113TN, United Kingdom
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Walker A, Boaz A, Hurley MV. The role of leadership in implementing and sustaining an evidence-based intervention for osteoarthritis (ESCAPE-pain) in NHS physiotherapy services: a qualitative case study. Disabil Rehabil 2020; 44:1313-1320. [PMID: 32755420 DOI: 10.1080/09638288.2020.1803997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To explore the role of leadership by physiotherapists in implementing and sustaining an evidence-based complex intervention (ESCAPE-pain) for osteoarthritis. MATERIALS AND METHODS A qualitative case study approach using in-depth interviews with 23 clinicians and managers from 4 National Health Service (NHS) physiotherapy providers in England between 2016 and 2017. Data were analysed using thematic analysis. RESULTS Different leadership roles and actions were characterised with four themes: (1) Clinical champions - clinicians driving the sustainability of ESCAPE-pain; (2) Supporters - junior clinicians directly supporting clinical champions' efforts to sustain ESCAPE-pain; (3) Senior Manager - clinical champions' senior managers influence on sustainability; (4) Decision-making - (in)formal processes underpinning decisions to (not) sustain the programme. CONCLUSIONS The study characterises the role of leadership in physiotherapy to sustain an evidence-based intervention for osteoarthritis (OA) within the NHS. Sustaining the intervention required on-going leadership, it did not stop at implementation. Senior specialist physiotherapists (as Champions) had a critical leadership role in driving sustainability. Their structural position (bridging the operational and strategic) and personal attributes allowed them to integrate different levels of leadership (i.e., senior managers and operational staff) to mobilise the collective, on-going work required for sustaining the programme.IMPLICATIONS FOR REHABILITATIONSenior managers and clinicians in practice settings need to be aware that sustaining an intervention is an on-going, collective effort that continues post-implementation.Senior managers need to enable senior clinicians (who straddle strategic and operational functions) to have sufficient autonomy to access and mobilise resources and scope to restructure local systems and practice to support intervention sustainability.Operational staff need to be supported to have the practical know-how to deliver evidence-based intervention, which includes instilling the value of and a commitment for the interventions.Managers need to utilise dispersed leadership to empower and enthuse frontline clinicians to participate fully in the work to refine and sustain interventions, because it cannot be achieved by lone individuals.
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Affiliation(s)
- Andrew Walker
- Faculty of Health, Social Care and Education, St George's, University of London, London, UK.,Faculty of Health, Social Care and Education, Kingston University, London, UK.,Health Innovation Network, London, UK
| | - Annette Boaz
- Faculty of Health, Social Care and Education, St George's, University of London, London, UK.,Faculty of Health, Social Care and Education, Kingston University, London, UK
| | - Michael V Hurley
- Faculty of Health, Social Care and Education, St George's, University of London, London, UK.,Faculty of Health, Social Care and Education, Kingston University, London, UK.,Health Innovation Network, London, UK
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11
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Implementing a fracture follow-up liaison service: perspective of key stakeholders. Rheumatol Int 2019; 40:607-614. [PMID: 31501995 DOI: 10.1007/s00296-019-04413-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
Fracture liaison services (FLS) have been shown to prevent efficiently subsequent fragility fractures (FF). However, very few studies have examined their implementation in depth. The purpose of this research was to identify factors influencing the implementation of a FLS at three sites in Quebec, Canada. From 2013 to 2015, individual and group interviews focused on experiences of FLS stakeholders, including implementation committee members, coordinators, and orthopaedic surgeons and their teams. Emerging key implementation factors were triangulated with the FLS patients' clinico-administrative data. The Consolidated Framework for Implementation Research guided the analysis of perceived factors influencing four intervention outputs: investigation of FF risk (using the FRAX score), communication with the participant primary care provider, initiation of anti-osteoporosis medications (when relevant), and referral to organized fall prevention activities (either governmental or community based). Among the 454 FLS patients recruited to the intervention group, 83% were investigated for FF risk, communication with the primary care provider was established for 98% of the participants, 54% initiated medication, and 35% were referred to organized fall prevention activities. Challenges related to restricted rights to prescribe medication and access to organized fall prevention activities were reported. FLS coordinator characteristics to overcome those challenges included self-efficacy beliefs, knowledge of community resources, and professional background. This study highlighted the importance of enabling access to services for subsequent FF prevention, consolidating the coordinator's role to facilitate a more integrated intervention, and involving local leaders to promote the successful implementation of the FLS.
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12
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Neuerburg C, Mittlmeier LM, Keppler AM, Westphal I, Glass Ä, Saller MM, Herlyn PKE, Richter H, Böcker W, Schieker M, Aszodi A, Fischer DC. Growth factor-mediated augmentation of long bones: evaluation of a BMP-7 loaded thermoresponsive hydrogel in a murine femoral intramedullary injection model. J Orthop Surg Res 2019; 14:297. [PMID: 31488155 PMCID: PMC6727400 DOI: 10.1186/s13018-019-1315-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/14/2019] [Indexed: 12/02/2022] Open
Abstract
Background Due to our aging population, an increase in proximal femur fractures can be expected, which is associated with impaired activities of daily living and a high risk of mortality. These patients are also at a high risk to suffer a secondary osteoporosis-related fracture on the contralateral hip. In this context, growth factors could open the field for regenerative approaches, as it is known that, i.e., the growth factor BMP-7 (bone morphogenetic protein 7) is a potent stimulator of osteogenesis. Local prophylactic augmentation of the proximal femur with a BMP-7 loaded thermoresponsive hydrogel during index surgery of an osteoporotic fracture could be suitable to reduce the risk of further osteoporosis-associated secondary fractures. The present study therefore aims to test the hypothesis if a BMP-7 augmented hydrogel is an applicable carrier for the augmentation of non-fractured proximal femurs. Furthermore, it needs to be shown that the minimally invasive injection of a hydrogel into the mouse femur is technically feasible. Methods In this study, male C57BL/6 mice (n = 36) received a unilateral femoral intramedullary injection of either 100 μl saline, 100 μl 1,4 Butan-Diisocyanat (BDI)-hydrogel, or 100 μl hydrogel loaded with 1 μg of bone morphogenetic protein 7. Mice were sacrificed 4 and 12 weeks later. The femora were submitted to high-resolution X-ray tomography and subsequent histological examination. Results Analysis of normalized CtBMD (Cortical bone mineral density) as obtained by X-ray micro-computed tomography analysis revealed significant differences depending on the duration of treatment (4 vs 12 weeks; p < 0.05). Furthermore, within different anatomically defined regions of interest, significant associations between normalized TbN (trabecular number) and BV/TV (percent bone volume) were noted. Histology indicated no signs of inflammation and no signs of necrosis and there were no cartilage damages, no new bone formations, or new cartilage tissues, while BMP-7 was readily detectable in all of the samples. Conclusions In conclusion, the murine femoral intramedullary injection model appears to be feasible and worth to be used in subsequent studies that are directed to examine the therapeutic potential of BMP-7 loaded BDI-hydrogel. Although we were unable to detect any significant osseous effects arising from the mode or duration of treatment in the present trial, the effect of different concentrations and duration of treatment in an osteoporotic model appears of interest for further experiments to reach translation into clinic and open new strategies of growth factor-mediated augmentation. Electronic supplementary material The online version of this article (10.1186/s13018-019-1315-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Lena M Mittlmeier
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.,Present Address: Department of Urology, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander M Keppler
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ines Westphal
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.,LivImplant GmbH, Starnberg, Germany
| | - Änne Glass
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, Research Group Biostatistics, Rostock University Medical Center, Rostock, Germany
| | - Maximilian M Saller
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Philipp K E Herlyn
- Department of Traumatology, Hand- and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany
| | - Heiko Richter
- LLS ROWIAK LaserLabSolutions GmbH, Hannover, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias Schieker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.,LivImplant GmbH, Starnberg, Germany
| | - Attila Aszodi
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Dagmar-C Fischer
- Department of Pediatrics, Rostock University Medical Center, Rostock, Germany
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13
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Willey SM, Gibson-Helm ME, Finch TL, East CE, Khan NN, Boyd LM, Boyle JA. Implementing innovative evidence-based perinatal mental health screening for women of refugee background. Women Birth 2019; 33:e245-e255. [PMID: 31182352 DOI: 10.1016/j.wombi.2019.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022]
Abstract
PROBLEM National guidelines recommend repeated screening for depression and anxiety for all women in the perinatal period. Routine screening in pregnancy is limited due to service, community and individual barriers. BACKGROUND Perinatal depression and perinatal anxiety affect up to 20% of all women. Women of refugee background are at even greater risk for perinatal mental health conditions due to refugee experiences and resettlement stressors. AIM To evaluate the acceptability and feasibility of a perinatal mental health screening program for women of refugee background from the perspective of health professionals. METHODS A mixed methods design guided by the Normalization Process Theory was used. Data were collected at a dedicated refugee antenatal clinic in the south-eastern suburbs of Melbourne, Australia. An online survey (n=38), focus groups (n=2; 13 participants) and semi-structured interviews (n=8; 11 participants) with health professionals were conducted. FINDINGS Under the four constructs of the Normalization Process Theory, health professionals reported improvements in identifying and referring women with mental health issues, more open and in-depth conversations with women about mental health and valued using an evidenced-based measure. Key issues included professional development, language barriers and time constraints. DISCUSSION Implementing a perinatal mental health screening program has been positively received. Strategies for sustainability include professional development and the addition of audio versions of the measures. CONCLUSION This perinatal mental health screening program is acceptable and a feasible option for health professionals. Health professionals value providing more holistic care and have more open discussion with women about mental health.
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Affiliation(s)
- Suzanne M Willey
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Level 1, 43-51 Kanooka Grove, Clayton, Victoria 3168, Australia.
| | - Melanie E Gibson-Helm
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Level 1, 43-51 Kanooka Grove, Clayton, Victoria 3168, Australia
| | - Tracy L Finch
- Department of Nursing, Midwifery & Health, Faculty of Health & Life Sciences, Northumbria University, Coach Lane Campus West, Newcastle upon Tyne NE7 7XA, United Kingdom
| | - Christine E East
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Level 1, 43-51 Kanooka Grove, Clayton, Victoria 3168, Australia; Monash Nursing and Midwifery, Monash University, Wellington Rd, Clayton, Victoria, 3168, Australia; Honorary, Monash Health, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Nadia N Khan
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Level 1, 43-51 Kanooka Grove, Clayton, Victoria 3168, Australia
| | - Leanne M Boyd
- Cabrini Institute, 154 Wattletree Rd, Malvern, Victoria 3144, Australia
| | - Jacqueline A Boyle
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Level 1, 43-51 Kanooka Grove, Clayton, Victoria 3168, Australia; Department of Obstetrics & Gynaecology, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
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14
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Abstract
In view of the high imminent risk of having subsequent fractures after a fracture, early evaluation and treatment decisions to prevent subsequent fractures are advocated. After a hip fracture, the fracture liaison service (FLS) and orthogeriatric care are considered the most appropriate organisational approaches for secondary fracture prevention following a recent fracture. Their introduction and implementation have been shown to increase evaluation and treatment of patients at high risk for subsequent fracture. Of real-world cohort studies, most, but not all studies, indicate a lower incidence of fracture and longer survival after treatment with nitrogen-containing bisphosphonates.
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Affiliation(s)
- Piet Geusens
- Department of Internal Medicine, Subdivision Rheumatology, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre +, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands; Biomedical Research Centre, Hasselt University, Agoralaan, Gebouw D, 3590 Diepenbeek, Belgium.
| | - Sandrine P G Bours
- Department of Internal Medicine, Subdivision Rheumatology, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre +, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - Caroline E Wyers
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, the Netherlands.
| | - Joop P van den Bergh
- Biomedical Research Centre, Hasselt University, Agoralaan, Gebouw D, 3590 Diepenbeek, Belgium; Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, the Netherlands.
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15
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Kanis JA, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019; 30:3-44. [PMID: 30324412 PMCID: PMC7026233 DOI: 10.1007/s00198-018-4704-5] [Citation(s) in RCA: 904] [Impact Index Per Article: 180.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis. INTRODUCTION The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting. METHODS Systematic reviews were updated. RESULTS The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
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16
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Inderjeeth CA, Raymond WD, Briggs AM, Geelhoed E, Oldham D, Mountain D. Implementation of the Western Australian Osteoporosis Model of Care: a fracture liaison service utilising emergency department information systems to identify patients with fragility fracture to improve current practice and reduce re-fracture rates: a 12-month analysis. Osteoporos Int 2018; 29:1759-1770. [PMID: 29704027 DOI: 10.1007/s00198-018-4526-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
UNLABELLED Fracture liaison service linked to an emergency department database effectively identifies patients with OP, improves best practice care, reduces recurrent fractures, and improves quality of life (QoL). The next step is to establish cost-effectiveness. This should be seen as the standard model of care. INTRODUCTION The Western Australian Osteoporosis Model of Care recommends implementation of a fracture liaison service (FLS) to manage patients with minimal trauma fractures (MTFs). This study evaluates the efficacy of a FLS linked to a tertiary hospital emergency department information system (EDIS) in reducing recurrent fractures. METHODS Patients aged ≥ 50 years with MTF identified from EDIS were invited to the FLS. Patient outcomes were compared to routine care (retrospective group-same hospital, and prospective group-other hospital) at 3- and 12-month follow-up. RESULTS Two hundred forty-one of 376 (64.1%) eligible patients participated in the FLS with 12 months of follow-up. Absolute risk of recurrent MTF at 12 months was reduced by 9.2 and 10.2% compared with the prospective and retrospective controls, respectively. After age/sex adjustment, FLS participants had less MTF at 12 months vs. the retrospective controls, OR 0.38 (95%CI 0.18-0.79), but not the prospective controls, OR 0.40 (95%CI 0.16-1.01). FLS patients were more likely to receive the 'best practice' care, i.e. awareness of osteoporosis, investigations, and treatment (all p < 0.05). 'Fallers' (OR 0.48 (95%CI 0.24, 0.96)) and fall rates were lower in the FLS (p = 0.001) compared to the prospective control. FLS experienced the largest improvement in QoL from 3 to 12 months as measured by the EuroQoL 5-domain (EQ-5D) UK weighted score (+ 15 vs. - 11 vs. - 16%, p < 0.001) and EQ-5D Health State visual analogue scale (+ 29 vs. - 2 vs. + 1%, p < 0.001). CONCLUSION Patients managed in a linked EDIS-FLS were more likely to receive the 'best practice' care and had lower recurrent MTF and improved QoL.
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Affiliation(s)
- C A Inderjeeth
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
- School of Medicine, The University of Western Australia, Perth, Australia.
- Arthritis and Osteoporosis Foundation of Western Australia, Shenton Park, Australia.
| | - W D Raymond
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
| | - A M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - E Geelhoed
- School of Population Health, The University of Western Australia, Perth, Australia
| | - D Oldham
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
| | - D Mountain
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
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17
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Desveaux L, Mitchell JI, Shaw J, Ivers NM. Understanding the impact of accreditation on quality in healthcare: A grounded theory approach. Int J Qual Health Care 2018; 29:941-947. [PMID: 29045664 DOI: 10.1093/intqhc/mzx136] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2017] [Indexed: 11/15/2022] Open
Abstract
Objective To explore how organizations respond to and interact with the accreditation process and the actual and potential mechanisms through which accreditation may influence quality. Design Qualitative grounded theory study. Setting Organizations who had participated in Accreditation Canada's Qmentum program during January 2014-June 2016. Participants Individuals who had coordinated the accreditation process or were involved in managing or promoting quality. Results The accreditation process is largely viewed as a quality assurance process, which often feeds in to quality improvement activities if the feedback aligns with organizational priorities. Three key stages are required for accreditation to impact quality: coherence, organizational buy-in and organizational action. These stages map to constructs outlined in Normalization Process Theory. Coherence is established when an organization and its staff perceive that accreditation aligns with the organization's beliefs, context and model of service delivery. Organizational buy-in is established when there is both a conceptual champion and an operational champion, and is influenced by both internal and external contextual factors. Quality improvement action occurs when organizations take purposeful action in response to observations, feedback or self-reflection resulting from the accreditation process. Conclusions The accreditation process has the potential to influence quality through a series of three mechanisms: coherence, organizational buy-in and collective quality improvement action. Internal and external contextual factors, including individual characteristics, influence an organization's experience of accreditation.
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Affiliation(s)
- L Desveaux
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, Ontario, Canada
| | | | - J Shaw
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, Ontario, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, Ontario, Canada
| | - N M Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, Ontario, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, Ontario, Canada
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18
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 316] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
PURPOSE OF REVIEW The purpose of this review is to report the evidence of beneficial effects of Fracture Liaison Service (FLS) including data regarding their impact on subsequent fracture, mortality risk and cost-effectiveness. This review also discusses the limitations of these data and the challenges faced during the implementation of FLS. RECENT FINDINGS Recent studies showed the beneficial impact of implementation of FLS on the prevention of subsequent fracture risk, reduced mortality and cost-effectiveness. However, heterogeneity of FLS models and small number of studies limited the conclusion about the impact of FLS on secondary fracture prevention. SUMMARY Patients with osteoporosis-related fractures are at higher risk of subsequent refractures. These subsequent fractures are associated with increased morbidity and premature mortality. However, there is a gap between evidence-based recommendations for postfracture care and actual clinical practice. FLS care is recommended for the management of the prevention of secondary fracture. FLS implementation reduces the risk of subsequent fracture, but the level of evidence is low as the interpretation of data is limited by the number of studies and their heterogeneity. FLS care significantly reduces the postfracture mortality, especially in patients with hip fractures. FLS implementation is cost-effective compared with usual care. Additional studies (with large sample and long-term follow-up) are needed to assess the impact of FLS care on subsequent fracture risk.
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20
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Venugopal Menon K, Al Harthy HHS, Al Habsi KSK, Al Ruzaiqi HAH. Are we treating osteoporotic fractures of the hip adequately? A Middle Eastern cohort study. Arch Osteoporos 2018; 13:6. [PMID: 29368309 DOI: 10.1007/s11657-018-0417-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/21/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Fragility hip fractures treated in a center in the Middle East were retrospectively studied for adequacy of osteoporosis management. Of the 318 patients treated, over 70% did not have a structured investigation and about 30% did not receive any therapeutic supplements. Our series showed a preventable 8.8% secondary fracture rate. PURPOSE To study the adequacy of evaluation and treatment of osteoporosis after fragility fractures of the hip. The study also attempts to estimate the prevalence of secondary fractures after the original injury. METHODS This is a retrospective evaluation of the electronic database to search all the admissions for fractures of the hip in patients over 50 years at a tertiary care Trauma and Orthopaedic center in the Sultanate of Oman. The study period was defined as October 2010 to December 2015. Their case records, BMD reports, and laboratory data were analyzed. Pharmacological interventions and the documented compliance with such therapy were also recorded. RESULTS Over the study period, 318 fragility fractures of the hip were treated. Of these, 233 (73.3%) did not receive a DEXA scan and 94% did not have their vitamin D3 (vit D) tested. About 29.9% percent cases did not receive any nutritional supplement or therapeutic intervention though diagnosed as fragility fracture. Twenty-eight patients (8.8%) reported for secondary fractures of the hip. Of these, 86% was initiated on supplement after their index fracture though 78.6% had not had a BMD study. CONCLUSIONS Less than 27% patients receive BMD test following fragility fracture of the hip and only 6% a vit D3 assay. Secondary fractures of the hip tend to occur in approximately 9% of the cases in Oman; this seems to occur equally in patients who have had as well as not had any calcium and vit D supplements after the index injury.
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Segrott J, Murphy S, Rothwell H, Scourfield J, Foxcroft D, Gillespie D, Holliday J, Hood K, Hurlow C, Morgan-Trimmer S, Phillips C, Reed H, Roberts Z, Moore L. An application of Extended Normalisation Process Theory in a randomised controlled trial of a complex social intervention: Process evaluation of the Strengthening Families Programme (10-14) in Wales, UK. SSM Popul Health 2017; 3:255-265. [PMID: 29302612 PMCID: PMC5742638 DOI: 10.1016/j.ssmph.2017.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 12/14/2016] [Accepted: 01/10/2017] [Indexed: 11/20/2022] Open
Abstract
Purpose Process evaluations generate important data on the extent to which interventions are delivered as intended. However, the tendency to focus only on assessment of pre-specified structural aspects of fidelity has been criticised for paying insufficient attention to implementation processes and how intervention-context interactions influence programme delivery. This paper reports findings from a process evaluation nested within a randomised controlled trial of the Strengthening Families Programme 10–14 (SFP 10–14) in Wales, UK. It uses Extended Normalisation Process Theory to theorise how interaction between SFP 10–14 and local delivery systems - particularly practitioner commitment/capability and organisational capacity - influenced delivery of intended programme activities: fidelity (adherence to SFP 10–14 content and implementation requirements); dose delivered; dose received (participant engagement); participant recruitment and reach (intervention attendance). Methods A mixed methods design was utilised. Fidelity assessment sheets (completed by practitioners), structured observation by researchers, and routine data were used to assess: adherence to programme content; staffing numbers and consistency; recruitment/retention; and group size and composition. Interviews with practitioners explored implementation processes and context. Results Adherence to programme content was high - with some variation, linked to practitioner commitment to, and understanding of, the intervention’s content and mechanisms. Variation in adherence rates was associated with the extent to which multi-agency delivery team planning meetings were held. Recruitment challenges meant that targets for group size/composition were not always met, but did not affect adherence levels or family engagement. Targets for staffing numbers and consistency were achieved, though capacity within multi-agency networks reduced over time. Conclusions Extended Normalisation Process Theory provided a useful framework for assessing implementation and explaining variation by examining intervention-context interactions. Findings highlight the need for process evaluations to consider both the structural and process components of implementation to explain whether programme activities are delivered as intended and why. Uses Extended Normalisation Process Theory to theorise intervention implementation. The Strengthening Families Programme was delivered with good overall fidelity. Adherence to planned content and staffing guidelines was high, with some variation. Recruitment of families was challenging and affected group size/composition Intervention-context interactions shaped variation in fidelity and implementation.
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Affiliation(s)
- Jeremy Segrott
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Heath Park, Cardiff CF14 4YS, United Kingdom
| | - Simon Murphy
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - Heather Rothwell
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - Jonathan Scourfield
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - David Foxcroft
- Faculty of Health and Life Sciences, Oxford Brookes University, Marston Campus, Oxford OX3 0FL, United Kingdom
| | - David Gillespie
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Heath Park, Cardiff CF14 4YS, United Kingdom
| | - Jo Holliday
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - Kerenza Hood
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Heath Park, Cardiff CF14 4YS, United Kingdom
| | - Claire Hurlow
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - Sarah Morgan-Trimmer
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - Ceri Phillips
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea SA2 8PP, United Kingdom
| | - Hayley Reed
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, United Kingdom.,Cardiff School of Social Sciences, Cardiff University, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT, United Kingdom
| | - Zoe Roberts
- Centre for Medical Education, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Laurence Moore
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Top floor, 200 Renfield Street, Glasgow G2 3QB, United Kingdom
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Lennox L, Doyle C, Reed JE, Bell D. What makes a sustainability tool valuable, practical and useful in real-world healthcare practice? A mixed-methods study on the development of the Long Term Success Tool in Northwest London. BMJ Open 2017; 7:e014417. [PMID: 28947436 PMCID: PMC5623390 DOI: 10.1136/bmjopen-2016-014417] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Although improvement initiatives show benefits to patient care, they often fail to sustain. Models and frameworks exist to address this challenge, but issues with design, clarity and usability have been barriers to use in healthcare settings. This work aimed to collaborate with stakeholders to develop a sustainability tool relevant to people in healthcare settings and practical for use in improvement initiatives. DESIGN Tool development was conducted in six stages. A scoping literature review, group discussions and a stakeholder engagement event explored literature findings and their resonance with stakeholders in healthcare settings. Interviews, small-scale trialling and piloting explored the design and tested the practicality of the tool in improvement initiatives. SETTING National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL). PARTICIPANTS CLAHRC NWL improvement initiative teams and staff. RESULTS The iterative design process and engagement of stakeholders informed the articulation of the sustainability factors identified from the literature and guided tool design for practical application. Key iterations of factors and tool design are discussed. From the development process, the Long Term Success Tool (LTST) has been designed. The Tool supports those implementing improvements to reflect on 12 sustainability factors to identify risks to increase chances of achieving sustainability over time. The Tool is designed to provide a platform for improvement teams to share their own views on sustainability as well as learn about the different views held within their team to prompt discussion and actions. CONCLUSION The development of the LTST has reinforced the importance of working with stakeholders to design strategies which respond to their needs and preferences and can practically be implemented in real-world settings. Further research is required to study the use and effectiveness of the tool in practice and assess engagement with the method over time.
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Affiliation(s)
- Laura Lennox
- Department of Medicine, CLAHRC for Northwest London, London, UK
- Department of Medicine, Imperial College London, London, UK
| | | | - Julie E Reed
- NIHR CLAHRC for Northwest London, London, UK
- Department of Public Health and Primary Care, Imperial College London, London, UK
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23
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Mitchell P, Åkesson K, Chandran M, Cooper C, Ganda K, Schneider M. Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Pract Res Clin Rheumatol 2017; 30:536-558. [PMID: 27886945 DOI: 10.1016/j.berh.2016.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/09/2016] [Accepted: 09/10/2016] [Indexed: 12/29/2022]
Abstract
As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered.
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Affiliation(s)
- Paul Mitchell
- Synthesis Medical NZ Limited, Pukekohe, New Zealand; University of Notre Dame Australia, Sydney, Australia; Osteoporosis New Zealand, Wellington, New Zealand.
| | - Kristina Åkesson
- Department of Orthopaedics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20 College Road, 169856, Singapore
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; National Institute of Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, The Botnar Research Centre, University of Oxford, Oxford, UK
| | - Kirtan Ganda
- The University of Sydney, Concord Clinical School and Concord Repatriation General Hospital, 1A Hospital Road, Concord Hospital, NSW, 2139, Australia
| | - Muriel Schneider
- International Osteoporosis Foundation, 9, Rue Juste-Olivier, 1260, Nyon, Switzerland
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24
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Leidel S, Leslie G, Boldy D, Girdler S. A comprehensive theoretical framework for the implementation and evaluation of opt-out HIV testing. J Eval Clin Pract 2017; 23:301-307. [PMID: 27451938 DOI: 10.1111/jep.12602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/14/2016] [Accepted: 06/16/2016] [Indexed: 11/30/2022]
Abstract
Opt-out HIV testing (in which patients are offered HIV testing as a default) is a potentially powerful strategy for increasing the number of people who know their HIV status and thus limiting viral transmission. Like any change in clinical practice, implementation of opt-out HIV testing in a health service requires a change management strategy, which should have theoretical support. This paper considers the application of three theories to the implementation and evaluation of an opt-out HIV testing programme: Behavioural Economics, the Health Belief Model and Normalisation Process Theory. An awareness, understanding and integration of these theories may motivate health care providers to order HIV tests that they may not routinely order, influence their beliefs about who should be tested for HIV and inform the operational aspects of opt-out HIV testing. Ongoing process evaluation of opt-out HIV testing programmes (based on these theories) will help to achieve individual health care provider self-efficacy and group collective action, thereby improving testing rates and health outcomes.
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Affiliation(s)
- Stacy Leidel
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Gavin Leslie
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Duncan Boldy
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Sonya Girdler
- School of Occupational Therapy and Social Work, Curtin University, Perth, Australia
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Abstract
BACKGROUND Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. DISCUSSION We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. CONCLUSION Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
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Affiliation(s)
- Carl R May
- Faculty of Health Sciences, University of Southampton, Building 67 (Nightingale), University Road, Highfield, Southampton, SO17 1BJ, UK. .,University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,NIHR CLAHRC Wessex, University of Southampton, Southampton, UK.
| | - Mark Johnson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Tracy Finch
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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26
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Abstract
BACKGROUND Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. DISCUSSION We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. CONCLUSION Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
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27
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Shulver W, Killington M, Crotty M. 'Massive potential' or 'safety risk'? Health worker views on telehealth in the care of older people and implications for successful normalization. BMC Med Inform Decis Mak 2016; 16:131. [PMID: 27733195 PMCID: PMC5062826 DOI: 10.1186/s12911-016-0373-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 10/07/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Telehealth technologies, which enable delivery of healthcare services at distance, offer promise for responding to the challenges created by an ageing population. However, successful implementation of telehealth into mainstream healthcare systems has been slow and fraught with failure. Understanding of frontline providers' experiences and attitudes regarding telehealth is a crucial aspect of successful implementation. This study aims to examine healthcare worker views on telehealth, and their implications for implementation to mainstream healthcare services for older people. The study includes a focus on two further dimensions of urban versus rural services and level of clinician experience with telehealth. METHODS Seven semi-structured focus groups were conducted with a total of 44 healthcare workers providing services to older people in the areas of rehabilitation and allied health, residential aged care and palliative care. Focus groups included both telehealth experienced and inexperienced groups. Of the experienced groups, two provided services to both urban and rural patients, and two to rural patients. Inexperienced groups included one rural and two urban. Thematic analysis was undertaken to identify predominant themes. Between-group differences and agreement in viewpoints for each of these themes are discussed and mapped to the theoretical constructs of Normalization Process Theory. RESULTS The views of participants varied with the extent of telehealth experience and perception of accessibility of healthcare services. Four themes describing clinician attitudes and perceptions that could impact on successful implementation of telehealth services are outlined: 1) Workability of telehealth: exponential growth in access or decay in the quality of healthcare? 2) What is an acceptable level of risk to patient safety with telehealth? 3) Shifting responsibilities and recalibrating the team; and 4) Change of architecture required to enable integration of telehealth service delivery. CONCLUSIONS The use of telehealth technologies to provide healthcare services to older people may be more readily normalized in areas where existing services are limited. Though exposure to telehealth may be a factor, changes to the perceived feasibility of telehealth in relation to conventional services, as well as supportive infrastructure and training and skill recalibration may be more critical to successful normalization of telehealth services for older people.
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Affiliation(s)
- Wendy Shulver
- Rehabilitation, Aged and Extended Care, Flinders University, Daws Road, Daw Park, Adelaide, South Australia, Australia.
| | - Maggie Killington
- Rehabilitation, Aged and Extended Care, Flinders University, Daws Road, Daw Park, Adelaide, South Australia, Australia.,Rehabilitation and Aged Care, Repatriation General Hospital, Adelaide, South Australia, Australia
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, Flinders University, Daws Road, Daw Park, Adelaide, South Australia, Australia.,Rehabilitation and Aged Care, Repatriation General Hospital, Adelaide, South Australia, Australia
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28
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Fogelman Y, Goldshtein I, Segal E, Ish-Shalom S. Managing Osteoporosis: A Survey of Knowledge, Attitudes and Practices among Primary Care Physicians in Israel. PLoS One 2016; 11:e0160661. [PMID: 27494284 PMCID: PMC4975485 DOI: 10.1371/journal.pone.0160661] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 07/23/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Osteoporosis is a systemic skeletal disorder characterized by impaired bone quality and microstructural deterioration leading to an increased propensity to fractures. This is a major health problem for older adults, which comprise an increasingly greater proportion of the general population. Due to a large number of patients and the insufficient availability of specialists in Israel and worldwide, osteoporosis is treated in large part by primary care physicians. We assessed the knowledge of primary care physicians on the diagnosis and treatment of osteoporosis. METHODS Physician's knowledge, sources of knowledge acquisition and self-evaluation of knowledge were assessed using a multiple choice questionnaire. Professional and demographic characteristics were assessed as well. RESULTS Of 490 physicians attending a conference, 363 filled the questionnaires (74% response rate). The physicians demonstrated better expertise in diagnosis than in medications (mechanism of action, side effects or contra-indications) but less than for other treatment related decisions. Overall, 50% demonstrated adequate knowledge of calcium and vitamin D supplementation, 51% were aware of the main therapeutic purpose of osteoporosis pharmacotherapy and 3% were aware that bisphosphonates should be avoided in patients with impaired renal function. Respondents stated frontal lectures at meetings as their main source of information on the subject. CONCLUSION The study indicates the need to intensify efforts to improve the knowledge of primary care physicians regarding osteoporosis, in general; and osteoporosis pharmacotherapy, in particular.
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Affiliation(s)
- Yacov Fogelman
- Department of Family Practice, Leumit Health Services Tel aviv, Israel.,The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Inbal Goldshtein
- Epidemiology and Database Research, Maccabi Healthcare Services, Tel-Aviv, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Elena Segal
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Endocrinology, Rambam Health Care Campus, Haifa, Israel
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29
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Drew S, Judge A, Cooper C, Javaid MK, Farmer A, Gooberman-Hill R. Secondary prevention of fractures after hip fracture: a qualitative study of effective service delivery. Osteoporos Int 2016; 27:1719-27. [PMID: 26759249 PMCID: PMC4839047 DOI: 10.1007/s00198-015-3452-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 12/03/2015] [Indexed: 10/26/2022]
Abstract
UNLABELLED There is variation in how services to prevent secondary fractures after hip fracture are delivered and no consensus on best models of care. This study identifies healthcare professionals' views on effective care for the prevention of these fractures. It is hoped this will provide information on how to develop services. INTRODUCTION Hip fracture patients are at high risk of subsequent osteoporotic fractures. Whilst fracture prevention services are recommended, there is variation in delivery and no consensus on best models of care. This study aims to identify healthcare professionals' views on effective care for prevention of secondary fracture after hip fracture. METHODS Forty-three semi-structured interviews were undertaken with healthcare professionals involved in delivering fracture prevention across 11 hospitals in one English region. Interviews explored views on four components of care: (1) case finding, (2) osteoporosis assessment, (3) treatment initiation, and (4) monitoring and coordination. Interviews were audio-recorded, transcribed, anonymised and coded using NVivo software. RESULTS Case finding: a number of approaches were discussed. Multiple methods ensured there was a 'backstop' if patients were overlooked. Osteoporosis assessment: there was no consensus on who should conduct this. The location of the dual energy X-ray absorptiometry (DXA) scanner influenced the likelihood of patients receiving a scan. Treatment initiation: it was felt this was best done in inpatients rather request initiation in the post-discharge/outpatients period. Monitoring (adherence): adherence was a major concern, and participants felt more monitoring could be conducted by secondary care. Coordination of care: participants advocated using dedicated coordinators and formal and informal methods of communication. A gap between primary and secondary care was identified and strategies suggested for addressing this. CONCLUSIONS A number of ways of organising effective fracture prevention services after hip fracture were identified. It is hoped that this will help professionals identify gaps in care and provide information on how to develop services.
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Affiliation(s)
- S Drew
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK.
| | - A Judge
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - C Cooper
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - M K Javaid
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - A Farmer
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - R Gooberman-Hill
- School of Clinical Sciences, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
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Qualitative Insights from the Osteoporosis Research: A Narrative Review of the Literature. J Osteoporos 2016; 2016:7915041. [PMID: 27994908 PMCID: PMC5138461 DOI: 10.1155/2016/7915041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/16/2016] [Accepted: 10/16/2016] [Indexed: 12/20/2022] Open
Abstract
Purpose. Much of the research on osteoporosis has been generated quantitatively. However, the qualitative osteoporosis literature provides valuable information on patient and clinician experiences and perspectives, informing the design and implementation of health research and healthcare services. To identify knowledge gaps and inform the design of future qualitative research, a narrative review was conducted to consolidate and synthesize the existing insights available within the qualitative osteoporosis research. Methods. Search terms reflecting the domains of osteoporosis and qualitative research were entered into the Scopus database to generate a comprehensive survey of qualitative research in the area of osteoporosis. Articles were thematically analysed and the results are presented in the form of a narrative review. Results. Forty-four articles were included in the narrative review. Qualitative research in the field of osteoporosis research can be summarized by 3 thematic areas: the meaning of osteoporosis for patients and the public, the lived experience of an osteoporosis diagnosis, and the programmatic approach to osteoporosis prevention and treatment. Conclusions. Qualitative studies provide clinically valuable insights in how osteoporosis is conceptualized and managed and programmatic aspects of osteoporosis treatment. The findings of this narrative review suggest the need for balance between presenting osteoporosis as a serious health condition and producing unwarranted anxiety and inactivity so as to ensure the best possible outcomes for individuals with osteoporosis.
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