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Reinoso Schiller N, Bludau A, Mathes T, König A, von Landesberger T, Scheithauer S. Unpacking nudge sensu lato: insights from a scoping review. J Hosp Infect 2024; 143:168-177. [PMID: 37949370 DOI: 10.1016/j.jhin.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.
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Affiliation(s)
- N Reinoso Schiller
- Department for Infection Control and Infectious Diseases, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany.
| | - A Bludau
- Department for Infection Control and Infectious Diseases, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
| | - T Mathes
- Department of Medical Statistics, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
| | - A König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
| | - T von Landesberger
- Chair for Visualization and Visual Analytics, University of Cologne, Cologne, Germany
| | - S Scheithauer
- Department for Infection Control and Infectious Diseases, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
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Indarwati F, Munday J, Keogh S. Peripheral intravenous catheter insertion, maintenance and outcomes in Indonesian paediatric hospital settings: A point prevalence study. J Pediatr Nurs 2023; 73:106-112. [PMID: 37659338 DOI: 10.1016/j.pedn.2023.08.009] [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: 02/28/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 09/04/2023]
Abstract
PURPOSE This study aimed to assess peripheral intravenous catheter use, maintenance practices, and outcomes of paediatric patients in a developing country setting. DESIGN AND METHODS A point prevalence survey using validated checklist was conducted between March and April 2022 in ten hospitals in Indonesia. A total number of 478 participants were approached during the audit. Data were obtained from site observation and medical records. RESULTS Of the 386 patients surveyed, >90% (362) had one catheter in-situ. The catheters were mostly inserted by nurses (331, 86%), primarily in the dorsum of the hand (207, 54%) with the purpose of delivering intravenous infusions and medications (367, 95%). Simple transparent dressings (176, 46%) with splint and bandage (295, 76%) were predominantly used for securement methods. Insertion sites were not visible for 182 (47%) patients, and 151 (40%) of daily care practices were poorly documented. Complications were documented in the medical record for 166 (43%) catheters. Adjusted analysis indicated that patient diagnosis, ward, catheter size, location, dressings, infusate, and flushing administration were significantly associated with complications. CONCLUSIONS Findings indicate that issues related to paediatric intravenous catheter complications in Indonesia are comparable to developed country settings. Ongoing surveillance is important to evaluate the management practices to benchmark against guidelines, optimise patient safety, and improve outcomes. PRACTICE IMPLICATIONS Results demonstrate low and middle-income countries face similar challenges with catheter insertion and care. The study indicates the importance of applying vascular access needs assessments, providing training for inserters, identifying optimum dressing methods, and optimising documentation.
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Affiliation(s)
- Ferika Indarwati
- Queensland University of Technology (QUT), School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia; School of Nursing, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia; Alliance of Vascular Access Teaching and Research Group, Griffith University, Queensland, Australia.
| | - Judy Munday
- Queensland University of Technology (QUT), School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia; Faculty of Health and Nursing Sciences, University of Agder, Grimstad, Norway.
| | - Samantha Keogh
- Queensland University of Technology (QUT), School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia; Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Alliance of Vascular Access Teaching and Research Group, Griffith University, Queensland, Australia.
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Fernando M, Abell B, Tyack Z, Donovan T, McPhail SM, Naicker S. Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review. J Med Internet Res 2023; 25:e45163. [PMID: 37851492 PMCID: PMC10620641 DOI: 10.2196/45163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 08/18/2023] [Accepted: 09/14/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Computerized clinical decision support systems (CDSSs) are essential components of modern health system service delivery, particularly within acute care settings such as hospitals. Theories, models, and frameworks may assist in facilitating the implementation processes associated with CDSS innovation and its use within these care settings. These processes include context assessments to identify key determinants, implementation plans for adoption, promoting ongoing uptake, adherence, and long-term evaluation. However, there has been no prior review synthesizing the literature regarding the theories, models, and frameworks that have informed the implementation and adoption of CDSSs within hospitals. OBJECTIVE This scoping review aims to identify the theory, model, and framework approaches that have been used to facilitate the implementation and adoption of CDSSs in tertiary health care settings, including hospitals. The rationales reported for selecting these approaches, including the limitations and strengths, are described. METHODS A total of 5 electronic databases were searched (CINAHL via EBSCOhost, PubMed, Scopus, PsycINFO, and Embase) to identify studies that implemented or adopted a CDSS in a tertiary health care setting using an implementation theory, model, or framework. No date or language limits were applied. A narrative synthesis was conducted using full-text publications and abstracts. Implementation phases were classified according to the "Active Implementation Framework stages": exploration (feasibility and organizational readiness), installation (organizational preparation), initial implementation (initiating implementation, ie, training), full implementation (sustainment), and nontranslational effectiveness studies. RESULTS A total of 81 records (42 full text and 39 abstracts) were included. Full-text studies and abstracts are reported separately. For full-text studies, models (18/42, 43%), followed by determinants frameworks (14/42,33%), were most frequently used to guide adoption and evaluation strategies. Most studies (36/42, 86%) did not list the limitations associated with applying a specific theory, model, or framework. CONCLUSIONS Models and related quality improvement methods were most frequently used to inform CDSS adoption. Models were not typically combined with each other or with theory to inform full-cycle implementation strategies. The findings highlight a gap in the application of implementation methods including theories, models, and frameworks to facilitate full-cycle implementation strategies for hospital CDSSs.
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Affiliation(s)
- Manasha Fernando
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Zephanie Tyack
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Thomasina Donovan
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Thorpe D, Strobel J, Bidargaddi N. Examining clinician choice to follow-up (or not) on automated notifications of medication non-adherence by clinical decision support systems. BMC Med Inform Decis Mak 2023; 23:22. [PMID: 36717855 PMCID: PMC9887874 DOI: 10.1186/s12911-022-02091-2] [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: 10/10/2021] [Accepted: 12/13/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Maintaining medication adherence can be challenging for people living with mental ill-health. Clinical decision support systems (CDSS) based on automated detection of problematic patterns in Electronic Health Records (EHRs) have the potential to enable early intervention into non-adherence events ("flags") through suggesting evidence-based courses of action. However, extant literature shows multiple barriers-perceived lack of benefit in following up low-risk cases, veracity of data, human-centric design concerns, etc.-to clinician follow-up in real-world settings. This study examined patterns in clinician decision making behaviour related to follow-up of non-adherence prompts within a community mental health clinic. METHODS The prompts for follow-up, and the recording of clinician responses, were enabled by CDSS software (AI2). De-identified clinician notes recorded after reviewing a prompt were analysed using a thematic synthesis approach-starting with descriptions of clinician comments, then sorting into analytical themes related to design and, in parallel, a priori categories describing follow-up behaviours. Hypotheses derived from the literature about the follow-up categories' relationships with client and medication-subtype characteristics were tested. RESULTS The majority of clients were Not Followed-up (n = 260; 78%; Followed-up: n = 71; 22%). The analytical themes emerging from the decision notes suggested contextual factors-the clients' environment, their clinical relationships, and medical needs-mediated how clinicians interacted with the CDSS flags. Significant differences were found between medication subtypes and follow-up, with Anti-depressants less likely to be followed up than Anti-Psychotics and Anxiolytics (χ2 = 35.196, 44.825; p < 0.001; v = 0.389, 0.499); and between the time taken to action Followed-up0 and Not-followed up1 flags (M0 = 31.78; M1 = 45.55; U = 12,119; p < 0.001; η2 = .05). CONCLUSION These analyses encourage actively incorporating the input of consumers and carers, non-EHR data streams, and better incorporation of data from parallel health systems and other clinicians into CDSS designs to encourage follow-up.
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Affiliation(s)
- Dan Thorpe
- grid.1014.40000 0004 0367 2697Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Adelaide, SA 5042 Australia
| | - Jörg Strobel
- grid.1014.40000 0004 0367 2697Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Adelaide, SA 5042 Australia ,grid.467022.50000 0004 0540 1022Barossa Hills Fleurieu Local Health Network, SA Health, 29 North St, Tarrawatta (Angaston), Peramangk Country, Adelaide, SA 5353 Australia
| | - Niranjan Bidargaddi
- grid.1014.40000 0004 0367 2697Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Adelaide, SA 5042 Australia
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Gallione C, Barisone M, Molon A, Pavani M, Torgano C, Bassi E, Dal Molin A. Extrinsic and intrinsic factors acting as barriers or facilitators in nurses' implementation of clinical practice guidelines: a mixed-method systematic review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022252. [PMID: 35775756 PMCID: PMC9335442 DOI: 10.23750/abm.v93i3.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Greater evaluations are needed to identify barriers or facilitators in nurses' guidelines adherence. The current review aims to explore extrinsic and intrinsic factors impacting nurses' compliance. METHODS Mixed-method systematic review with a convergent approach, following the PRISMA checklist and the JBI Mixed Methods Review Methodological Guidance was conducted. MEDLINE, Embase, CINAHL were systematically searched, to find studies published between 2010 and 2021, including qualitative, quantitative or mixed-methods articles. RESULTS Sixty studies were included, and the major findings were analysed by aggregating them in two main themes: intrinsic and extrinsic factors. The intrinsic factors were: a) knowledge and skills; b) attitudes of health personnel; c) sense of belonging towards guidelines. The extrinsic factors were: a) organizational and environmental factors; b) workload; c) guidelines structure; d) patients and caregivers' attitude. CONCLUSIONS The included studies report lack of resources, among environmental factors, as the main barrier perceived. Nurses, who are at the forefront in addressing the direct application of knowledge and skills to ensure patient safety, have a higher perception of this kind of barriers than other healthcare personnel. Potential facilitators emerged in the review are positive feedback and reinforcements at the workplace, either from the members of the team or from the leaders. Moreover, the level of active participation of the patient and caregiver could have a positive impact on nurses' guidelines adherence. Guidelines implementation remains a complex process, resulting in a strong recommendation to support health policymakers and nursing leaders in implementing continuing education programs.
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Affiliation(s)
- Chiara Gallione
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy, Maggiore della Carità University Hospital, Novara, Italy
| | - Michela Barisone
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | | | - Moreno Pavani
- Maggiore della Carità University Hospital, Novara, Italy
| | | | - Erika Bassi
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy, Maggiore della Carità University Hospital, Novara, Italy
| | - Alberto Dal Molin
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy, Maggiore della Carità University Hospital, Novara, Italy
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Santos LMD, Figueredo IB, Silva CSGE, Catapano UO, Silva BSM, Avelar AFM. Risk factors for infiltration in children and adolescents with peripheral intravenous catheters. Rev Bras Enferm 2022; 75:e20210176. [DOI: 10.1590/0034-7167-2021-0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objectives: to estimate the incidence of infiltration and the factors associated with its occurrence in children and adolescents in the operative period and with peripheral intravenous catheters. Methods: a longitudinal and prospective study with children and adolescents using peripheral intravenous catheters, conducted at the surgical clinic unit of a pediatric hospital in Feira de Santana, State of Bahia, from April 2015 to December 2016. The study used Pearson’s chi-square and Fisher’s exact test for the analysis. It also applied multiple analyses using Poisson regression with robust variance. Results: the incidence of infiltration was 31.2% and was associated with female sex (RR=0.53; CI=[0.30-0.96]), non-eutrophic children (RR=2.27; CI=[1.25-4.20]), who used non-irritating and non-vesicant drugs (RR=1.72; CI=[1.03-2.87]), vesicant drugs (RR=1.84; CI=[1.05-3.22]) and irritating/vesicant electrolytes (RR=2.35; CI=[1.38-3.97]). Conclusions: the study suggests the development of strategies that will help in the prevention of this adverse event through the knowledge of the associated factors.
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Mebrahtu TF, Skyrme S, Randell R, Keenan AM, Bloor K, Yang H, Andre D, Ledward A, King H, Thompson C. Effects of computerised clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes: a systematic review of experimental and observational studies. BMJ Open 2021; 11:e053886. [PMID: 34911719 PMCID: PMC8679061 DOI: 10.1136/bmjopen-2021-053886] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/22/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Computerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals' performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this. MATERIALS AND METHODS The following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion. RESULTS A total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile/handheld-technology. DISCUSSION CDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness. CONCLUSION CDSS may have a positive impact on selected aspects of nurses' and AHPs' performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing.
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Affiliation(s)
| | - Sarah Skyrme
- School of Healthcare, University of Leeds, Leeds, UK
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | | | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
| | - Huiqin Yang
- School of Healthcare, University of Leeds, Leeds, UK
| | | | | | - Henry King
- School of Healthcare, University of Leeds, Leeds, UK
| | - Carl Thompson
- School of Healthcare, University of Leeds, Leeds, UK
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Using Electronic Data and a Mixed-Methods Approach to Evaluate Short Peripheral Catheter Outcomes in Acute Care. JOURNAL OF INFUSION NURSING 2021; 44:147-156. [PMID: 33935249 DOI: 10.1097/nan.0000000000000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Short peripheral catheters (SPCs) are commonly used in hospitals, guided by evidence-based standards to optimize dwell time and limit adverse outcomes. Although SPC insertions are common, real-world evaluation is rare. A theory-based framework and mixed-methods design were used to analyze findings from a unit-level survey and electronic data to evaluate SPC care delivered on units at a large quaternary medical center over a 6-month period (quarters 1 and 2, 2017). Dissemination without adoption and maintenance may limit effectiveness. The convergent results confirmed the feasibility of extracting electronic data to be used by leaders to clinically evaluate staff knowledge and use behaviors to take action to improve outcomes.
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Reynolds SS, Woltz P, Keating E, Neff J, Elliott J, Hatch D, Yang Q, Granger BB. Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial. Implement Sci 2021; 16:45. [PMID: 33902653 PMCID: PMC8074470 DOI: 10.1186/s13012-021-01112-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates. METHODS A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability. RESULTS Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates. CONCLUSIONS Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices. TRIAL REGISTRATION ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.
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Affiliation(s)
- Staci S Reynolds
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA.
- Duke University Hospital, 2310 Erwin Road, Durham, NC, 27710, USA.
| | - Patricia Woltz
- WakeMed Health & Hospitals, 3000 New Bern Avenue, Raleigh, NC, 27610, USA
| | - Edward Keating
- Duke University Hospital, 2310 Erwin Road, Durham, NC, 27710, USA
| | - Janice Neff
- WakeMed Health & Hospitals, 3000 New Bern Avenue, Raleigh, NC, 27610, USA
| | - Jennifer Elliott
- WakeMed Health & Hospitals, 3000 New Bern Avenue, Raleigh, NC, 27610, USA
| | - Daniel Hatch
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Qing Yang
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Bradi B Granger
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
- Duke University Health System, 2310 Erwin Road, Durham, NC, 27710, USA
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Steffen KM, Holdsworth LM, Ford MA, Lee GM, Asch SM, Proctor EK. Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework. Implement Sci 2021; 16:15. [PMID: 33509190 PMCID: PMC7841901 DOI: 10.1186/s13012-021-01080-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/01/2021] [Indexed: 01/09/2023] Open
Abstract
Background Like in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). Very few prior studies have applied implementation science frameworks to understand how best to improve practices in this unique environment. We used the relatively new integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in the PICU and to explore the utility of the framework itself for that purpose. Methods We used the iPARIHS framework to guide development of a semi-structured interview tool to examine barriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developed around iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. We assessed the utility of iPARIHS to inform PICU practice change. Results Fifty multi-professional providers working in 8 U.S. PICUs completed interviews. iPARIHS constructs shaped the development of a process model for change that consisted of phases that include planning, a decision to adopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large, complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While the unit leaders made decisions to pursue change, providers’ willingness to accept change was based on the evidence for the change, and provider’s experiences, beliefs, and capacity to integrate change into a demanding workflow. Limited analytic structures and resources frustrated attempts to monitor changes’ impacts. Variable provider engagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructs were useful in exploring implementation; however, we identified inter-relation of subconstructs, unique concepts not captured by the framework, and a need for subconstructs to further describe facilitation. Conclusions The PICU environment significantly shaped the implementation. The described process model for implementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHS was adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs for facilitation would be helpful to operationalize the framework. Trial registration Not applicable, as no health care intervention was performed. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01080-9.
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Affiliation(s)
- Katherine M Steffen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University, 770 Welch Road, Suite 435, Palo Alto, CA, 94304, USA.
| | - Laura M Holdsworth
- Stanford Division of Primary Care and Population Health, Stanford, CA, USA
| | - Mackenzie A Ford
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Grace M Lee
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, Stanford Division of Primary Care and Population Health, Palo Alto, CA, USA
| | - Enola K Proctor
- George Warren Brown School of Social Work, Washington University in Saint Louis, Saint Louis, MO, USA
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Bergström A, Ehrenberg A, Eldh AC, Graham ID, Gustafsson K, Harvey G, Hunter S, Kitson A, Rycroft-Malone J, Wallin L. The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature. Implement Sci 2020; 15:68. [PMID: 32854718 PMCID: PMC7450685 DOI: 10.1186/s13012-020-01003-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework. METHODS This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail. RESULTS The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated. CONCLUSIONS In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.
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Affiliation(s)
- Anna Bergström
- Department of Women’s and Children’s health, Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Uppsala, Sweden
- Institute for Global Health, University College London, London, UK
| | - Anna Ehrenberg
- School of Education, Health, and Social Studies, Dalarna University, Falun, Sweden
- Adelaide Nursing School, University of Adelaide, Adelaide, Australia
| | - Ann Catrine Eldh
- Department of Medicine and Health, Linköping University, Linköping, Sweden
- Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden
| | - Ian D. Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kazuko Gustafsson
- School of Education, Health, and Social Studies, Dalarna University, Falun, Sweden
- University Library, Uppsala University, Uppsala, Sweden
| | - Gillian Harvey
- Adelaide Nursing School, University of Adelaide, Adelaide, Australia
| | - Sarah Hunter
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Alison Kitson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Green Templeton College, University of Oxford, Oxford, UK
| | - Jo Rycroft-Malone
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancashire, UK
| | - Lars Wallin
- School of Education, Health, and Social Studies, Dalarna University, Falun, Sweden
- Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Rogers L, De Brún A, McAuliffe E. Defining and assessing context in healthcare implementation studies: a systematic review. BMC Health Serv Res 2020; 20:591. [PMID: 32600396 PMCID: PMC7322847 DOI: 10.1186/s12913-020-05212-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 04/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The implementation of evidence-based healthcare interventions is challenging, with a 17-year gap identified between the generation of evidence and its implementation in routine practice. Although contextual factors such as culture and leadership are strong influences for successful implementation, context remains poorly understood, with a lack of consensus regarding how it should be defined and captured within research. This study addresses this issue by providing insight into how context is defined and assessed within healthcare implementation science literature and develops a definition to enable effective measurement of context. METHODS Medline, PsychInfo, CINAHL and EMBASE were searched. Articles were included if studies were empirical and evaluated context during the implementation of a healthcare initiative. These English language articles were published in the previous 10 years and included a definition and assessment of context. Results were synthesised using a narrative approach. RESULTS Three thousand and twenty-one search records were obtained of which 64 met the eligibility criteria and were included in the review. Studies used a variety of definitions in terms of the level of detail and explanation provided. Some listed contextual factors (n = 19) while others documented sub-elements of a framework that included context (n = 19). The remaining studies provide a rich definition of general context (n = 11) or aspects of context (n = 15). The Alberta Context Tool was the most frequently used quantitative measure (n = 4), while qualitative papers used a range of frameworks to evaluate context. Mixed methods studies used diverse approaches; some used frameworks to inform the methods chosen while others used quantitative measures to inform qualitative data collection. Most studies (n = 50) applied the chosen measure to all aspects of study design with a majority analysing context at an individual level (n = 29). CONCLUSIONS This review highlighted inconsistencies in defining and measuring context which emphasised the need to develop an operational definition. By providing this consensus, improvements in implementation processes may result, as a common understanding will help researchers to appropriately account for context in research.
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Affiliation(s)
- L. Rogers
- University College Dublin Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), Belfield, Dublin 4, Ireland
- University College Dublin School of Nursing, Midwifery and Health Systems, Belfield, Dublin 4, Ireland
| | - A. De Brún
- University College Dublin Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), Belfield, Dublin 4, Ireland
- University College Dublin School of Nursing, Midwifery and Health Systems, Belfield, Dublin 4, Ireland
| | - E. McAuliffe
- University College Dublin Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), Belfield, Dublin 4, Ireland
- University College Dublin School of Nursing, Midwifery and Health Systems, Belfield, Dublin 4, Ireland
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13
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Incidence of peripheral intravenous catheter failure and complications in paediatric patients: Systematic review and meta analysis. Int J Nurs Stud 2020; 102:103488. [DOI: 10.1016/j.ijnurstu.2019.103488] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/28/2019] [Accepted: 11/18/2019] [Indexed: 11/22/2022]
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Patient-focused outcomes are infrequently reported in pediatric health information technology trials: a systematic review. J Clin Epidemiol 2019; 119:117-125. [PMID: 31794805 DOI: 10.1016/j.jclinepi.2019.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/31/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Billions of dollars have been invested in Health Information Technologies (HITs), and randomized controlled trials (RCTs) have been conducted to identify the effects of these interventions. Our objective was to identify the types of outcomes that were measured and reported in these RCTs. STUDY DESIGN AND SETTING We completed a systematic review (Medline, EMBASE, and CENTRAL databases) of RCTs involving children (<18 years) and utilizing HIT interventions. RESULTS We identified 45 RCTs involving 323,945 children. Most studies reported process outcomes (n = 40/45 (88.9%)) but did not include patient-focused outcomes such as patient/carer functioning (n = 12/45 (26.7%)), clinical/physiological health (n = 10/45, 22.2%), quality of life (n = 3/45, 6.7%), or mortality (n = 1/45, 2.2%). Only 3 of 45 (6.7%) studies reported an evaluation of adverse events. In only 14 of 45 (31.1%) studies was it clear that all outcomes that were measured were reported. CONCLUSION It is difficult to use RCTs to fully evaluate the benefits and risks of using HIT interventions in pediatric health care settings because patient-focused outcomes and adverse events are rarely reported. Measures to improve the quality of future trials may include the publication of study protocols and the development of an outcome reporting framework or core outcome set.
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Andrew NE, Middleton S, Grimley R, Anderson CS, Donnan GA, Lannin NA, Stroil-Salama E, Grabsch B, Kilkenny MF, Squires JE, Cadilhac DA. Hospital organizational context and delivery of evidence-based stroke care: a cross-sectional study. Implement Sci 2019; 14:6. [PMID: 30658654 PMCID: PMC6339367 DOI: 10.1186/s13012-018-0849-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 12/07/2018] [Indexed: 01/19/2023] Open
Abstract
Background Organizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes. Methods This was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined. Results A total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1 year. There was good reliability (∞ 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (μ 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (μ 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medication at discharge (62.5% vs. 52.0%). Staff from higher context hospitals were more likely to value medical and/or nursing leadership and stroke care protocols. Conclusions Overall organizational context, and in particular aspects of culture and social capital, are associated with the delivery of some components of evidence-based stroke care, offering insights into potential pathways for improving the implementation of proven therapies. Electronic supplementary material The online version of this article (10.1186/s13012-018-0849-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadine E Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.,Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, Australia
| | - Rohan Grimley
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.,Sunshine Coast Clinical School, The University of Queensland, Birtinya and Statewide Stroke Clinical Network, Queensland Health, Brisbane, Australia
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Geoffrey A Donnan
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Natasha A Lannin
- Faculty of Health Sciences, La Trobe University, Bundoora, Australia.,Occupational Therapy Department, Alfred Health, Melbourne, Australia
| | - Enna Stroil-Salama
- Australian Bronchiectasis Registry, Lung Foundation Australia, Brisbane, Australia
| | - Brenda Grabsch
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Janet E Squires
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia. .,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.
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Fønhus MS, Dalsbø TK, Johansen M, Fretheim A, Skirbekk H, Flottorp SA. Patient-mediated interventions to improve professional practice. Cochrane Database Syst Rev 2018; 9:CD012472. [PMID: 30204235 PMCID: PMC6513263 DOI: 10.1002/14651858.cd012472.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals. OBJECTIVES To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice). SEARCH METHODS We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017. SELECTION CRITERIA Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE). MAIN RESULTS We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies. AUTHORS' CONCLUSIONS We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.
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Affiliation(s)
- Marita S Fønhus
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Therese K Dalsbø
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Marit Johansen
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Atle Fretheim
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Helge Skirbekk
- Norwegian National Advisory Unit on Learning and Mastery in Health, Oslo University HospitalOsloNorway0586
- Institute of Health and Society, Medical Faculty, University of OsloDepartment of Health Management and Health EconomicsOsloNorway
| | - Signe A. Flottorp
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
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