Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

OBJECTIVES

This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions.

ELIGIBILITY CRITERIA

We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework.

RESULTS

Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework.

CONCLUSIONS

Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Expanding access to telehealth in Australian cardiac rehabilitation services: a national survey of barriers, enablers, and uptake

Aims

Cardiac rehabilitation (CR) is traditionally delivered in-person; however, the COVID-19 pandemic provided impetus for alternative offerings such as telehealth. We investigated uptake, barriers, and enablers in a national survey during the pandemic in Australia.

Methods and results

We surveyed CR programmes between April and June 2021 using professional association networks. The anonymous online questionnaire addressed programme characteristics, COVID-19 impacts, and barriers to and enablers of telehealth use. Open-text responses were coded and presented as themes. In total, there were responses from 105 programmes (33% response rate). All states and geographical areas were represented. The use of every modality of telehealth care (telephone, video conferencing, text messaging, and web-based) increased significantly during and after COVID with a strong preference for telephone (85% of services). Respondents perceived video (53%) and telephone (47%) formats as safe and effective for delivering CR. The most common barriers to telehealth were difficulties conducting assessments and reduced engagement with patients. Prominent enablers were increased reach and reduced patient barriers to CR access.

Conclusion

Telehealth use by CR programmes increased during the peak pandemic period. However, additional support is required to ensure that telehealth services can be maintained. There is considerable potential to increase the reach of CR by embedding telehealth into existing models of care.

Developing critical HIV health literacy: insights from interviews with priority migrant communities in Queensland, Australia

In Australia, surveillance data establish that there are higher rates of late HIV diagnoses among heterosexual migrants from Sub-Saharan Africa and new HIV diagnoses among gay and bisexual men (GBM) from Southeast and Northeast Asia and Latin America. Together, these groups are identified as priority migrant communities in current efforts to eliminate HIV transmissions. HIV health literacy is recognised as a key means of improving access to services and health outcomes. This qualitative paper explores critical HIV health literacy among priority migrant communities in Queensland, Australia. To foreground community voices, peer researchers from priority migrant communities participated in the project design, data collection and analysis, with 20 interviews completed. The findings demonstrate how participants' engagement with HIV health information and services is highly relational and situated within the framework of sexual health and wellbeing. Participants strategically selected where to seek information and who they trusted to help them appraise this information. They further demonstrated reflective capacities in identifying the contextual barriers that inhibit the development of their HIV health literacy. The findings highlight the need for HIV health promotion strategies that embrace a sex positive approach, promote cultural change, and involve collaboration with general practitioners (GPs).

Geographical challenges and inequity of healthcare access for high-risk paediatric heart disease

BACKGROUND

Geographical context is an important consideration for health system design to promote equality in access to care for patients with childhood heart disease (CHD), particularly those living in regional, rural, and remote areas. To help inform future policy and practice recommendations, this study aimed to (i) describe the geographic distribution of high-risk CHD patients accessing an Australian state-wide specialist service and (ii) estimate travel time for accessing healthcare via general practitioners (primary), nearest paediatric centre (secondary) and specialist paediatric cardiac centre (tertiary).

METHODS

Participants included a cohort of children (0-18 year) who accessed state-wide specialist CHD services over a 3-year period (2019-2021) in Queensland, Australia. Locations for patient residence, general practitioner, closest paediatric centre and tertiary cardiac centre were mapped using geographical information system (GIS) software (ArcGIS Online). Travel distance and times were estimated using a Google Maps Application Programming Interface (API).

RESULTS

1019 patients (median age 3.8 years) had cardiac intervention and were included in the sample. Of this cohort, 30.2% lived outside the heavily urbanised South East Queensland (SEQ) area where the tertiary centre is located. These patients travel substantially further and longer to access tertiary level care (but not secondary or primary level care) compared to those in SEQ. Median distance for patients residing outside SEQ to access tertiary care was 953 km with a travel time of 10 h 43 min. This compares to 5.5 km to the general practitioner and 20.6 km to a paediatric service (8.9 and 54 min respectively).

CONCLUSION

This geographical mapping of CHD services has demonstrated a key challenge inherent in providing specialist cardiac care to children in a large state-based healthcare system. A significant proportion of high-risk patients live large distances from tertiary level care. The greater accessibility of primary care services highlights the importance of supporting primary care physicians outside metropolitan areas to acquire or build the ability and capacity to care for children with CHD. Strengthening local primary and secondary services not only has the potential to improve the outcomes of high-risk patients, but also to reduce costs and burden associated with potentially avoidable travel from regional, rural, or remote areas to access specialist CHD services.

Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review

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.

Preferences in the Design and Delivery of Neurodevelopmental Follow-Up Care for Children: A Systematic Review of Discrete Choice Experiments

Neurodevelopmental disorders are a significant cause of morbidity. Early detection of neurodevelopmental delay is essential for timely diagnosis and intervention, and it is therefore important to understand the preferences of parents and clinicians for engaging with neurodevelopmental surveillance and follow-up care. Discrete choice experiment (DCE) may be an appropriate method for quantifying these preferences. This review systematically examined how DCEs have been designed and delivered in studies examining neurodevelopmental care of children and identified the preferred attributes that have been reported. PubMed, Embase, CINAHL, and Scopus databases were systematically searched. Studies were included if they used DCE to elicit preferences for a neurodevelopmental follow-up program for children. Two independent reviewers conducted the title and abstract and full-text screening. Risk of bias was assessed using a DCE-specific checklist. Findings were presented using a narrative synthesis. A total of 6618 records were identified and 16 papers were included. Orthogonal (n=5) and efficient (n=5) experimental designs were common. There was inconsistent reporting of design-related features. Analysis was primarily completed using mixed logit (n=6) or multinomial logit (n=3) models. Several key attributes for neurodevelopmental follow-up care were identified including social, behavioral and emotional support, therapy, waiting time, and out-of-pocket costs. DCE has been successfully used as a preference elicitation method for neurodevelopmental-related care. There is scope for improvement in the design and analysis of DCE in this field. Nonetheless, attributes identified in these studies are likely to be important considerations in the design and implementation of programs for neurodevelopmental care.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Identifying barriers and facilitators to successful implementation of computerized clinical decision support systems in hospitals: a NASSS framework-informed scoping review

BACKGROUND

Successful implementation and utilization of Computerized Clinical Decision Support Systems (CDSS) in hospitals is complex and challenging. Implementation science, and in particular the Nonadoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework, may offer a systematic approach for identifying and addressing these challenges. This review aimed to identify, categorize, and describe barriers and facilitators to CDSS implementation in hospital settings and map them to the NASSS framework. Exploring the applicability of the NASSS framework to CDSS implementation was a secondary aim.

METHODS

Electronic database searches were conducted (21 July 2020; updated 5 April 2022) in Ovid MEDLINE, Embase, Scopus, PyscInfo, and CINAHL. Original research studies reporting on measured or perceived barriers and/or facilitators to implementation and adoption of CDSS in hospital settings, or attitudes of healthcare professionals towards CDSS were included. Articles with a primary focus on CDSS development were excluded. No language or date restrictions were applied. We used qualitative content analysis to identify determinants and organize them into higher-order themes, which were then reflexively mapped to the NASSS framework.

RESULTS

Forty-four publications were included. These comprised a range of study designs, geographic locations, participants, technology types, CDSS functions, and clinical contexts of implementation. A total of 227 individual barriers and 130 individual facilitators were identified across the included studies. The most commonly reported influences on implementation were fit of CDSS with workflows (19 studies), the usefulness of the CDSS output in practice (17 studies), CDSS technical dependencies and design (16 studies), trust of users in the CDSS input data and evidence base (15 studies), and the contextual fit of the CDSS with the user's role or clinical setting (14 studies). Most determinants could be appropriately categorized into domains of the NASSS framework with barriers and facilitators in the "Technology," "Organization," and "Adopters" domains most frequently reported. No determinants were assigned to the "Embedding and Adaptation Over Time" domain.

CONCLUSIONS

This review identified the most common determinants which could be targeted for modification to either remove barriers or facilitate the adoption and use of CDSS within hospitals. Greater adoption of implementation theory should be encouraged to support CDSS implementation.

Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis

BACKGROUND

Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context.

METHODS

Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses.

RESULTS

Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective.

CONCLUSION

Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.

Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice

OBJECTIVE

Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations.

MATERIALS AND METHODS

A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist.

RESULTS

Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups.

DISCUSSION AND CONCLUSION

Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.

Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey

BACKGROUND

The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice.

METHODS

An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March-December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May-July 2021).

RESULTS

Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR-exercise and education-were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support.

CONCLUSION

Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations.

Implementation costs of hospital-based computerised decision support systems: a systematic review

BACKGROUND

The importance of accurately costing implementation strategies is increasingly recognised within the field of implementation science. However, there is a lack of methodological guidance for costing implementation, particularly within digital health settings. This study reports on a systematic review of costing analyses conducted alongside implementation of hospital-based computerised decision support systems.

METHODS

PubMed, Embase, Scopus and CINAHL databases were searched between January 2010 and August 2021. Two reviewers independently screened and selected original research studies that were conducted in a hospital setting, examined the implementation of a computerised decision support systems and reported implementation costs. The Expert Recommendations for Implementing Change Framework was used to identify and categorise implementation strategies into clusters. A previously published costing framework was applied to describe the methods used to measure and value implementation costs. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

Titles and abstracts of 1836 articles were screened, with nine articles eligible for inclusion in the review. Implementation costs were most frequently reported under the 'evaluative and iterative strategies' cluster, followed by 'provide interactive assistance'. Labour was the largest implementation-related cost in the included papers, irrespective of implementation strategy. Other reported costs included consumables, durable assets and physical space, which was mostly associated with stakeholder training. The methods used to cost implementation were often unclear. There was variation across studies in the overall quality of reporting.

CONCLUSIONS

A relatively small number of papers have described computerised decision support systems implementation costs, and the methods used to measure and value these costs were not well reported. Priorities for future research should include establishing consistent terminology and appropriate methods for estimating and reporting on implementation costs.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (ID: CRD42021272948).

The Cost of Neurodevelopmental Disability: Scoping Review of Economic Evaluation Methods

The provision of effective care models for children with neurodevelopmental delay or disability can be challenging in resource constrained healthcare systems. Economic evaluations have an important role in informing resource allocation decisions. This review systematically examined the scope and methods of economic models evaluating interventions for supporting neurodevelopment among children with common neurodevelopmental disorders and identified methods of economic models and presented policy implications. This scoping review employed the Arksey and O'Malley framework and aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Four electronic databases were systematically searched to identify eligible model-based economic evaluations of neurodevelopmental care models published since 2000. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to assess quality of reporting. Data were systematically extracted, tabulated, and qualitatively synthesised across diagnostic categories. Searches identified 1431 unique articles. Twelve studies used a decision analytic model to evaluate care for neurodevelopmental disorders and were included in the review. Included studies focused on attention-deficit/hyperactivity disorder (ADHD, n=6), autism spectrum disorder (ASD, n=3), cerebral palsy (n=2), and dyslexia (n=1). The most used decision analytic modelling approach was a Markov model (n=6), followed by a decision tree (n=3), and a combination of decision tree and Markov model (n=3). Most studies (n=7) adopted a societal perspective for reporting costs. None of the reviewed studies modelled impact on families and caregivers. Four studies reported cost-savings, three identified greater quality of life, and three identified cost increases.

Impact and outcome evaluation of HealthPathways: a scoping review of published methodologies

INTRODUCTION The HealthPathways programme is an online health information system used mainly in primary health care to promote a consistent and integrated approach to patient care. AIM The aim of this study is to perform a scoping review of the methodologies used in published impact and outcomes evaluations of HealthPathways programmes. METHODS The review included qualitative, quantitative or mixed-methods evaluations of the impact or outcome of HealthPathways. MEDLINE, Embase, CINAHL and Web of Science databases were searched. Seven programme aims were identified in the impact and outcome evaluation: (1) increased awareness and use of HealthPathways; (2) general practitioners are supported to adopt best practice, patient-centred care; (3) increased appropriate use of resources and services; (4) improved quality of referrals; (5) enhanced consistent care and management of health conditions; (6) improved patient journeys through the local health system; and (7) reduction in health-care cost and increased value for money. RESULTS Twenty-one studies were included in the final review; 15 were research papers and six were reports. 'Increased awareness and use of HealthPathways' was the most frequent programme aim evaluated (n = 12). Quantitative and qualitative research methodologies, as well as prospective and retrospective data collections, have been adopted to evaluate the impact and outcome of HealthPathways. DISCUSSION Assessing the impacts and outcomes of HealthPathways may be challenging due to limitations in primary data and the interconnectedness of change across the measured aims. Each aim may therefore require specific methodologies sensitive enough to capture the impact that HealthPathways are making over time.

Cost-effectiveness of interventions for musculoskeletal foot and ankle conditions: a systematic review

OBJECTIVE

Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise and synthesise the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions.

METHODS

Electronic databases were searched for studies presenting economic evaluations of non-surgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35).

RESULTS

Thirty-six studies were identified reporting non-surgical interventions (n=10), non-surgical versus surgical interventions (n=14) and surgical interventions (n=12). The most common conditions were osteoarthritis, ankle fracture and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the non-surgical alternative.

CONCLUSION

Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle complaints to best inform future clinical practice guidelines.

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

BACKGROUND

While the clinical benefits of exercise-based cardiac rehabilitation are well established, there is extensive variation in the interventions used within these trials. It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes. This study aims to systematically examine the relationship between individual components of the exercise intervention in cardiac rehabilitation (such as intensity and frequency) and clinical outcomes for people with coronary heart disease.

METHODS

In this systematic review, eligible trials were identified via searches of databases (PubMed, Allied and Complementary Medicine, EMBASE, PEDro, Science Citation Index Expanded, CINAHL, The Cochrane Library, SPORTDiscus) from citation tracking and hand-searching. Studies were included if they were randomised trials of a structured exercise intervention (versus usual care) for participants with coronary heart disease and reported at least one of cardiovascular mortality, total mortality, myocardial infarction or revascularisation outcomes. Each included trial was assessed using the Cochrane Risk of Bias Tool. Authors were also contacted for missing intervention details or data. Random effects meta-analysis was performed to calculate a summary risk ratio (RR) with 95% confidence interval (CI) for the effect of exercise on outcomes. Random effects meta-regression and subgroup analyses were conducted to examine the association between pre-specified co-variates (exercise components or trial characteristics) and each clinical outcome.

RESULTS

Sixty-nine trials were included, evaluating 72 interventions which differed markedly in terms of exercise components. Exercise-based cardiac rehabilitation was effective in reducing cardiovascular mortality (RR 0.74, 95% CI 0.65 to 0.86), total mortality (RR 0.90, 95% CI 0.83 to 0.99) and myocardial infarction (RR 0.80, 95% CI 0.70 to 0.92). This effect generally demonstrated no significant differences across subgroups of patients who received various types of usual care, more or less than 150 min of exercise per week and of differing cardiac aetiologies. There was however some heterogeneity observed in the efficacy of cardiac rehabilitation in reducing total mortality based on the presence of lipid lowering therapy (I 2 = 48%, p = 0.15 for subgroup treatment interaction effect). No single exercise component was identified through meta-regression as a significant predictor of mortality outcomes, although reductions in both total (RR 0.81, p = 0.042) and cardiovascular mortality (RR 0.72, p = 0.045) were observed in trials which reported high levels of participant exercise adherence, versus those which reported lower levels. A dose-response relationship was found between an increasing exercise session time and increasing risk of myocardial infarction (RR 1.01, p = 0.011) and the highest intensity of exercise prescribed and an increasing risk of percutaneous coronary intervention (RR 1.05, p = 0.047).

CONCLUSIONS

Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease. While our analysis was constrained by the quality of included trials and missing information about intervention components, there appears to be little differential effect of variations in exercise intervention, particularly on mortality outcomes. Given the observed effect between higher adherence and improved outcomes, it may be more important to provide exercise-based cardiac rehabilitation programs which focus on achieving increased adherence to the exercise intervention.

Parent-Child Interaction Therapy: A Meta-analysis

CONTEXT

Parent-child interaction therapy (PCIT) is effective at reducing children's externalizing behavior. However, modifications are often made to PCIT, and it is not known whether these impact effectiveness.

OBJECTIVE

To systematically review and meta-analyze the effects of PCIT on child externalizing behaviors, considering modifications, study design, and bias.

DATA SOURCES

We searched PubMed, PsycINFO, Education Resources Information Center, Sociological Abstracts, and A+ Education.

STUDY SELECTION

We selected randomized controlled or quasi-experimental trials.

DATA EXTRACTION

We analyzed child externalizing and internalizing behaviors, parent stress, parent-child interactions, PCIT format, and study design and/or characteristics.

RESULTS

We included 23 studies (1144 participants). PCIT was superior to control for reducing child externalizing (standardized mean difference [SMD]: -0.87, 95% confidence interval [CI]:-1.17 to -0.58). PCIT studies that required skill mastery had significantly greater reductions in externalizing behavior than those that did not (Mastery: SMD: -1.09, 95% CI: -1.44 to -0.73; Nonmastery: SMD: -0.51,95% CI: -0.85 to -0.17, P = .02). Compared with controls, PCIT significantly reduced parent-related stress (mean difference [MD]: -6.98, 95% CI: -11.69 to -2.27) and child-related stress (MD: -9.87, 95% CI: -13.64 to -6.09). Children in PCIT were observed to be more compliant to parent requests (SMD: 0.89, 95% CI: 0.50 to 1.28) compared with controls. PCIT effectiveness did not differ depending on session length, location (academic versus community settings), or child problems (disruptive behaviors only compared with disruptive behavior and other problems).

LIMITATIONS

Results for parent-child observations were inconsistently reported, reducing the ability to pool important data.

CONCLUSIONS

PCIT has robust positive outcomes across multiple parent-reported and observed parent-child interaction measures, and modifications may not be required even when implemented in diverse populations.

Exploration of the methodological quality and clinical usefulness of a cross-sectional sample of published guidance about exercise training and physical activity for the secondary prevention of coronary heart disease

BACKGROUND

Clinicians are encouraged to use guidelines to assist in providing evidence-based secondary prevention to patients with coronary heart disease. However, the expanding number of publications providing guidance about exercise training may confuse cardiac rehabilitation clinicians. We therefore sought to explore the number, scope, publication characteristics, methodological quality, and clinical usefulness of published exercise-based cardiac rehabilitation guidance.

METHODS

We included publications recommending physical activity, exercise or cardiac rehabilitation for patients with coronary heart disease. These included systematically developed clinical practice guidelines, as well as other publications intended to support clinician decision making, such as position papers or consensus statements. Publications were obtained via electronic searches of preventive cardiology societies, guideline databases and PubMed, to November 2016. Publication characteristics were extracted, and two independent assessors evaluated quality using the 23-item Appraisal of Guidelines Research and Evaluation II (AGREE) tool.

RESULTS

Fifty-four international publications from 1994 to 2016 were identified. Most were found on preventive cardiology association websites (n = 35; 65%) and were freely accessible (n = 50; 93%). Thirty (56%) publications contained only broad recommendations for physical activity and cardiac rehabilitation referral, while 24 (44%) contained the necessary detailed exercise training recommendations. Many were labelled as "guidelines", however publications with other titles (e.g. scientific statements) were common (n = 24; 44%). This latter group of publications contained a significantly greater proportion of detailed exercise training recommendations than clinical guidelines (p = 0.017). Wide variation in quality also existed, with 'applicability' the worst scoring AGREE II domain for clinical guidelines (mean score 53%) and 'rigour of development' rated lowest for other guidance types (mean score 33%).

CONCLUSIONS

While a large number of guidance documents provide recommendations for exercise-based cardiac rehabilitation, most have limitations in either methodological quality or clinical usefulness. The lack of rigorously developed guidelines which also contain necessary detail about exercise training remains a substantial problem for clinicians.

Exercise training characteristics in cardiac rehabilitation programmes: a cross-sectional survey of Australian practice

Introduction

Exercise training is a core component of cardiac rehabilitation (CR), however, little information exists regarding the specific exercise interventions currently provided for coronary heart disease in Australian practice. We aimed to analyse the current status of exercise-based CR services across Australia.

Design

Cross-sectional survey.

Methods

Australian sites offering exercise-based CR were identified from publically available directories. All sites were invited by email to participate in an online Survey Monkey questionnaire between October 2014 and March 2015, with reminders via email and phone follow-up. Questions investigated the demographics and format of individual programmes, as well as specific exercise training characteristics.

Results

297 eligible programmes were identified, with an 82% response rate. Most sites (82%) were based at hospital or outpatient centres, with home (15%), community (18%) or gym-based options (5%) less common. While CR was most often offered in a comprehensive format (72% of sites), the level of exercise intervention varied greatly among programmes. Most frequently, exercise was prescribed 1–2 times per week for 60 min over 7 weeks. Almost one-quarter (24%) had a sole practitioner supervising exercise, although the majority used a nurse/physiotherapist combination. Low to moderate exercise intensities were used in 60% of programmes, however, higher intensity prescriptions were not uncommon. Few sites (<6%) made use of technology, such as mobile phones or the internet, to deliver or support exercise training.

Conclusions

While advances have been made towards providing flexible and accessible exercise-based CR, much of Australia's service remains within traditional models of care. A continuing focus on service improvement and evidence-based care should, therefore, be considered a core aim of those providing exercise for CR in order to improve health service delivery and optimise outcomes for patients.

Topics of conflict between parents and young adolescents

ISSUES AND PURPOSE

Parents often examine and question interactions with their young teen and may ask the advice of healthcare professionals. Topics, frequency, and intensity of conflicts between young adolescents and parents were therefore examined.

DESIGN AND METHODS

A descriptive survey using the 44-item Issues Checklist (Robin, 1975) with 163 parent and young adolescent (ages 11-14) dyads.

RESULTS

Parents and teens were congruent about their reports of the topics, frequency, and intensity of conflict. Discussion of the topics generally was not angry. Mothers reported the greatest quantity of issues. Potentially sensitive topics such as substance use, dating, and sex were rarely approached by either parent or young adolescent. Sociodemographic characteristics did not distinguish or were not associated with IC scores.

PRACTICE IMPLICATIONS

Conflict is a common component of the parent-young adolescent relationship. Families with children entering adolescence can expect conflict about issues that recur but usually are not that "hot". Anticipating topics may put conflict in perspective. Nurses help families resolve conflicts associated with day-to-day conflicts as a first step toward opening up larger, potentially sensitive topics.