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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [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: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Haskell L, Tavender EJ, O'Brien S, Wilson CL, Borland ML, Cotterell E, Babl FE, Zannino D, Sheridan N, Oakley E, Dalziel SR. Can targeted interventions change the factors influencing variation in management of infants with bronchiolitis? A survey of Australian and New Zealand clinicians: A paediatric research in emergency departments international collaborative (PREDICT) study. J Paediatr Child Health 2022; 58:302-311. [PMID: 34498782 DOI: 10.1111/jpc.15710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to determine whether targeted interventions, proven to be effective at improving evidence-based bronchiolitis management, changed factors previously found to influence variation in bronchiolitis management. METHODS This survey assessed change in factors influencing clinicians' (nurses and doctors) bronchiolitis management at baseline and post-intervention in a cluster randomised controlled trial of targeted, theory-informed interventions aiming to de-implement non-evidence-based bronchiolitis management (no use of chest X-ray, salbutamol, antibiotics, glucocorticoids and adrenaline). Survey questions addressed previously identified factors influencing bronchiolitis management from six Theoretical Domains Framework domains (knowledge; skills; beliefs about consequences; social/professional role and identity; environmental context and resources; social influences). Data analysis was descriptive. RESULTS A total of 1958 surveys (baseline = 996; post-intervention = 962) were completed by clinicians from the emergency department and paediatric inpatient units from 26 hospitals (intervention = 13; control = 13). Targeted bronchiolitis interventions significantly increased knowledge of the Australasian Bronchiolitis Guideline (intervention clinicians = 74%, control = 39%, difference = 34.7%, 95% confidence interval (CI) = 25.6-43.8%), improved skills in diagnosing (intervention doctors = 89%, control = 76%, difference = 12.6%, 95% CI = 6.2-19%) and managing bronchiolitis (intervention doctors = 87%, control = 76%, difference = 9.9%, 95% CI = 3.7-16.1%), positively influenced both beliefs about consequences regarding salbutamol use (intervention clinicians = 49%, control = 29%, difference = 20.3%, 95% CI = 13.2-27.4%) and nurses questioning non-evidence-based bronchiolitis management (chest X-ray: intervention = 71%, control = 51%, difference = 20.8%, 95% CI = 11.4-30.2%; glucocorticoids: intervention = 64%, control = 40%, difference = 21.9%, 95% CI = 10.4-33.5%) (social/professional role and identity). A 14% improvement in evidence-based bronchiolitis management favouring intervention hospitals was demonstrated in the cluster randomised controlled trial. CONCLUSION Targeted interventions positively changed factors influencing bronchiolitis management resulting in improved evidence-based bronchiolitis care. This study has important implications for improving bronchiolitis management and future development of interventions to de-implement low-value care.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Nursing, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Diana Zannino
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Paediatric Research in Emergency Departments International Collaborative (PREDICT), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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3
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Schadewaldt V, McElduff B, D'Este C, McInnes E, Dale S, Fasugba O, Cadilhac DA, Considine J, Grimshaw JM, Cheung NW, Levi C, Gerraty R, Fitzgerald M, Middleton S. Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes. Nurs Outlook 2020; 69:103-115. [PMID: 32981669 DOI: 10.1016/j.outlook.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/22/2020] [Accepted: 08/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency departments (ED) are challenging environments but critical for early management of patients with stroke. PURPOSE To identify how context affects the provision of stroke care in 26 Australian EDs. METHOD Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. FINDINGS Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. DISCUSSION Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.
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Affiliation(s)
- Verena Schadewaldt
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia.
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Catherine D'Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australia; School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Oyebola Fasugba
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Julie Considine
- Deakin University - Eastern Health; School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Victoria, Australia
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital - General Campus, Centre for Practice-Changing Research (CPCR), Ottawa, Ontario, Canada
| | - N Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Westmead, Sydney, New South Wales, Australia
| | - Chris Levi
- The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South Wales, Liverpool, New South Wales, Australia
| | - Richard Gerraty
- Department of Medicine, Monash University, Melbourne, Australia
| | - Mark Fitzgerald
- Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia; Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
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Weir A, Kitto S, Smith J, Presseau J, Colman I, Hatcher S. Barriers and enablers to conducting cluster randomized control trials in hospitals: A theory-informed scoping review. EVALUATION AND PROGRAM PLANNING 2020; 80:101815. [PMID: 32146300 DOI: 10.1016/j.evalprogplan.2020.101815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/01/2020] [Accepted: 02/29/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Cluster randomized control trials (cRCTs) have unique challenges compared to single site trials with regards to conduct of the trial, and it is important to understand these barriers. The aim of this scoping review was to describe the current literature surrounding the implementation of the cRCTs in hospitals. METHODS The search strategy was designed to identify literature relevant to conduct of cRCTs, with hospitals as the unit of randomization. Data was extracted and was mapped using the Consolidated Framework for Implementation Research (CFIR) as a codebook, which contains 39 constructs organized into five domains. RESULTS Twenty-two articles met inclusion criteria and were included. 18 of 39 constructs of the CFIR were identified in coding, spanning four of the five domains. Barriers to the conduct of the trial were rarely reported as the main outcome of the study, and few details were included in the identified literature. CONCLUSIONS The review can provide guidance to future researchers planning cRCTs in hospitals. It also identified a large gap in reporting of conduct of these trials, demonstrating the need for a research agenda that further explores the barriers and facilitators, with the aim of garnering knowledge for improved guidance in the implementation.
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Affiliation(s)
- Arielle Weir
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Simon Kitto
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, K1H 8M5, Canada
| | - Jennifer Smith
- Population Health, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, K1N 7K4, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, K1H 8L6, Canada
| | - Ian Colman
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada
| | - Simon Hatcher
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, K1H 8L6, Canada
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Bosch M, McKenzie JE, Ponsford JL, Turner S, Chau M, Tavender EJ, Knott JC, Gruen RL, Francis JJ, Brennan SE, Pearce A, O'Connor DA, Mortimer D, Grimshaw JM, Rosenfeld JV, Meares S, Smyth T, Michie S, Green SE. Evaluation of a targeted, theory-informed implementation intervention designed to increase uptake of emergency management recommendations regarding adult patients with mild traumatic brain injury: results of the NET cluster randomised trial. Implement Sci 2019; 14:4. [PMID: 30654826 PMCID: PMC6337860 DOI: 10.1186/s13012-018-0841-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 11/22/2018] [Indexed: 01/22/2023] Open
Abstract
Background Evidence-based guidelines for management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available; however, clinical practice remains inconsistent with these guidelines. A targeted, theory-informed implementation intervention (Neurotrauma Evidence Translation (NET) intervention) was designed to increase the uptake of three clinical practice recommendations regarding the management of patients who present to Australian EDs with mild head injuries. The intervention involved local stakeholder meetings, identification and training of nursing and medical local opinion leaders, train-the-trainer workshops and standardised education materials and interactive workshops delivered by the opinion leaders to others within their EDs during a 3 month period. This paper reports on the effects of this intervention. Methods EDs (clusters) were allocated to receive either access to a clinical practice guideline (control) or the implementation intervention, using minimisation, a method that allocates clusters to groups using an algorithm to minimise differences in predefined factors between the groups. We measured clinical practice outcomes at the patient level using chart audit. The primary outcome was appropriate screening for post-traumatic amnesia (PTA) using a validated tool until a perfect score was achieved (indicating absence of acute cognitive impairment) before the patient was discharged home. Secondary outcomes included appropriate CT scanning and the provision of written patient information upon discharge. Patient health outcomes (anxiety, primary outcome: Hospital Anxiety and Depression Scale) were also assessed using follow-up telephone interviews. Outcomes were assessed by independent auditors and interviewers, blinded to group allocation. Results Fourteen EDs were allocated to the intervention and 17 to the control condition; 1943 patients were included in the chart audit. At 2 months follow-up, patients attending intervention EDs (n = 893) compared with control EDs (n = 1050) were more likely to have been appropriately assessed for PTA (adjusted odds ratio (OR) 20.1, 95%CI 6.8 to 59.3; adjusted absolute risk difference (ARD) 14%, 95%CI 8 to 19). The odds of compliance with recommendations for CT scanning and provision of written patient discharge information were small (OR 1.2, 95%CI 0.8 to 1.6; ARD 3.2, 95%CI − 3.7 to 10 and OR 1.2, 95%CI 0.8 to 1.8; ARD 3.1, 95%CI − 3.0 to 9.3 respectively). A total of 343 patients at ten interventions and 14 control sites participated in follow-up interviews at 4.3 to 10.7 months post-ED presentation. The intervention had a small effect on anxiety levels (adjusted mean difference − 0.52, 95%CI − 1.34 to 0.30; scale 0–21, with higher scores indicating greater anxiety). Conclusions Our intervention was effective in improving the uptake of the PTA recommendation; however, it did not appreciably increase the uptake of the other two practice recommendations. Improved screening for PTA may be clinically important as it leads to appropriate periods of observation prior to safe discharge. The estimated intervention effect on anxiety was of limited clinical significance. We were not able to compare characteristics of EDs who declined trial participation with those of participating sites, which may limit the generalizability of the results. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12612001286831), date registered 12 December 2012. Electronic supplementary material The online version of this article (10.1186/s13012-018-0841-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marije Bosch
- Department of Surgery, Monash University, Melbourne, Australia. .,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia. .,Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands.
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, Australia.,School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Simon Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marisa Chau
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Emma J Tavender
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Jonathan C Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia.,Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L Gruen
- National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jill J Francis
- School of Health Sciences, City University of London, London, UK
| | - Sue E Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Pearce
- MedSTAR Emergency Medical Retrieval Service, Adelaide, Australia.,Royal Adelaide Hospital Emergency Department, Adelaide, Australia
| | - Denise A O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Australia
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Australia
| | - Susanne Meares
- Department of Psychology, Macquarie University, Sydney, Australia
| | - Tracy Smyth
- Emergency Department, Westmead Hospital, Sydney, Australia
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Sally E Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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6
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Mortimer D, Bosch M, Mckenzie JE, Turner S, Chau M, Ponsford JL, Knott JC, Gruen RL, Green SE. Economic evaluation of the NET intervention versus guideline dissemination for management of mild head injury in hospital emergency departments. Implement Sci 2018; 13:147. [PMID: 30518430 PMCID: PMC6280545 DOI: 10.1186/s13012-018-0834-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available, and yet, clinical practice remains inconsistent with the guidelines. The Neurotrauma Evidence Translation (NET) intervention was developed to increase the uptake of guideline recommendations and improve the management of minor head injury in Australian emergency departments (EDs). However, the adoption of this type of intervention typically entails an upfront investment that may or may not be fully offset by improvements in clinical practice, health outcomes and/or reductions in health service utilisation. The present study estimates the cost and cost-effectiveness of the NET intervention, as compared to the passive dissemination of the guideline, to evaluate whether any improvements in clinical practice or health outcomes due to the NET intervention can be obtained at an acceptable cost. METHODS AND FINDINGS Study setting: The NET cluster randomised controlled trial [ACTRN12612001286831]. STUDY SAMPLE Seventeen EDs were randomised to the control condition and 14 to the intervention. One thousand nine hundred forty-three patients were included in the analysis of clinical practice outcomes (NET sample). A total of 343 patients from 14 control and 10 intervention EDs participated in follow-up interviews and were included in the analysis of patient-reported health outcomes (NET-Plus sample). OUTCOME MEASURES Appropriate post-traumatic amnesia (PTA) screening in the ED (primary outcome). Secondary clinical practice outcomes: provision of written information on discharge (INFO) and safe discharge (defined as CT scan appropriately provided plus PTA plus INFO). Secondary patient-reported, post-discharge health outcomes: anxiety (Hospital Anxiety and Depression Scale), post-concussive symptoms (Rivermead), and preference-based health-related quality of life (SF6D). METHODS Trial-based economic evaluations from a health sector perspective, with time horizons set to coincide with the final follow-up for the NET sample (2 months post-intervention) and to 1-month post-discharge for the NET-Plus sample. RESULTS Intervention and control groups were not significantly different in health service utilisation received in the ED/inpatient ward following the initial mTBI presentation (adjusted mean difference $23.86 per patient; 95%CI - $106, $153; p = 0.719) or over the longer follow-up in the NET-plus sample (adjusted mean difference $341.78 per patient; 95%CI - $58, $742; p = 0.094). Savings from lower health service utilisation are therefore unlikely to offset the significantly higher upfront cost of the intervention (mean difference $138.20 per patient; 95%CI $135, $141; p < 0.000). Estimates of the net effect of the intervention on total cost (intervention cost net of health service utilisation) suggest that the intervention entails significantly higher costs than the control condition (adjusted mean difference $169.89 per patient; 95%CI $43, $297, p = 0.009). This effect is larger in absolute magnitude over the longer follow-up in the NET-plus sample (adjusted mean difference $505.06; 95%CI $96, $915; p = 0.016), mostly due to additional health service utilisation. For the primary outcome, the NET intervention is more costly and more effective than passive dissemination; entailing an additional cost of $1246 per additional patient appropriately screened for PTA ($169.89/0.1363; Fieller's 95%CI $525, $2055). For NET to be considered cost-effective with 95% confidence, decision-makers would need to be willing to trade one quality-adjusted life year (QALY) for 25 additional patients appropriately screened for PTA. While these results reflect our best estimate of cost-effectiveness given the data, it is possible that a NET intervention that has been scaled and streamlined ready for wider roll-out may be more or less cost-effective than the NET intervention as delivered in the trial. CONCLUSIONS While the NET intervention does improve the management of mTBI in the ED, it also entails a significant increase in cost and-as delivered in the trial-is unlikely to be cost-effective at currently accepted funding thresholds. There may be a scope for a scaled-up and streamlined NET intervention to achieve a better balance between costs and outcomes. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12612001286831 , date registered 12 December 2012.
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Affiliation(s)
- Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Australia.
| | - Marije Bosch
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Joanne E Mckenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Simon Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marisa Chau
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, Australia.,School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jonathan C Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia.,Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L Gruen
- National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Melbourne, Singapore
| | - Sally E Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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7
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Garner AS, Storfer-Isser A, Szilagyi M, Stein RE, Green CM, Kerker BD, O’Connor KG, Hoagwood KE, Horwitz SM. Promoting Early Brain and Child Development: Perceived Barriers and the Utilization of Resources to Address Them. Acad Pediatr 2017; 17:697-705. [PMID: 27890781 PMCID: PMC5443705 DOI: 10.1016/j.acap.2016.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/11/2016] [Accepted: 11/16/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent-child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers. METHODS Data were analyzed from 304 nontrainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease nonresponse bias. Bivariate comparisons and multivariable regression analyses were conducted. RESULTS At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent-child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent-child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent-child relationships, screening tools, and community resources. CONCLUSIONS Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.
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Affiliation(s)
- Andrew S. Garner
- Case Western Reserve University, School of Medicine, Cleveland, OH
| | | | - Moira Szilagyi
- University of California at Los Angeles, Los Angeles, CA
| | - Ruth E.K. Stein
- Albert Einstein College of Medicine/Children’s Hospital at Montefiore, New York, NY
| | - Cori M. Green
- New York-Presbyterian Hospital-Weill Cornell Medical College, New York, NY
| | - Bonnie D. Kerker
- Nathan Kline Institute of Psychiatric Research, Orangeburg, NY,Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, NY
| | | | - Kimberly E. Hoagwood
- Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, NY
| | - Sarah McCue Horwitz
- Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, NY
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Benzer JK, Charns MP, Hamdan S, Afable M. The role of organizational structure in readiness for change: A conceptual integration. Health Serv Manage Res 2016; 30:34-46. [PMID: 28166670 DOI: 10.1177/0951484816682396] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this review is to extend extant conceptualizations of readiness for change as an individual-level phenomenon. This review-of-reviews focuses on existing conceptual frameworks from the dissemination, implementation, quality improvement, and organizational transformation literatures in order to integrate theoretical rationales for how organization structure, a key dimension of the organizational context, may impact readiness for change. We propose that the organization structure dimensions of differentiation and integration impact readiness for change at the individual level of analysis by influencing four key concepts of relevance, legitimacy, perceived need for change, and resource allocation. We identify future research directions that focus on these four key concepts.
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Affiliation(s)
- Justin K Benzer
- 1 Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.,2 Department of Veterans Affairs, VISN 17 Center of Excellence for Research on Returning Veterans, Waco, TX, USA.,3 Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Martin P Charns
- 1 Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.,4 Department of Health Policy, Law, and Management, School of Public Health, Boston University, Boston, MA, USA
| | - Sami Hamdan
- 1 Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.,5 School of Medicine, Tufts University, Boston, MA, USA
| | - Melissa Afable
- 1 Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.,4 Department of Health Policy, Law, and Management, School of Public Health, Boston University, Boston, MA, USA
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