Identifying psychosocial predictors of medication non-adherence following acute coronary syndrome: A systematic review and meta-analysis

OBJECTIVE

Medication non-adherence following acute coronary syndrome (ACS) is associated with poor clinical outcomes. A systematic review and meta-analysis were undertaken to identify psychosocial factors associated with medication adherence in patients with ACS.

METHODS

A search of electronic databases (Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, International Pharmaceutical Abstracts, CINAHL, ASSIA, OpenGrey, EthOS and WorldCat) was undertaken to identify relevant articles published in English between 2000 and 2014. Articles were screened against our inclusion criteria and data on study design, sample characteristics, predictors, outcomes, analyses, key findings and study limitations were abstracted.

RESULTS

Our search identified 3609 records, of which 17 articles met our inclusion criteria (15 independent studies). Eight out of ten studies found an association between depression and non-adherence. A meta-analysis revealed that depressed patients were twice as likely to be non-adherent compared to patients without depression (OR=2.00, 95% CI 1.57-3.33, p=0.015). Type D personality was found to predict non-adherence in both studies in which it was measured. Three out of three studies reported that treatment beliefs based on the Necessity-Concerns Framework predicted medication non-adherence and there was some evidence that social support was associated with better adherence. There was insufficient data to meta-analyse all other psychosocial factors identified.

CONCLUSION

There was some evidence that psychosocial factors, particularly depression, were associated with medication adherence following ACS. Targeting depressive symptoms, screening for Type D personality, challenging maladaptive treatment beliefs, and providing better social support for patients may be useful strategies to improve medication adherence.

High resolution MIC genotyping: design and application to the investigation of inflammatory bowel disease susceptibility

The highly polymorphic nonclassical MHC class I chain-related (MIC) genes MICA and MICB encode stress inducible glycoproteins expressed on a variety of epithelial cells including intestinal cells. Interaction with the receptor NKG2D is likely to provide an important costimulatory signal for activation and proliferation of NK cells, activated macrophages and CD8 alphabeta and gammadelta T cells. Fifty-four MICA and 17 MICB alleles have been described to date. Although the functional significance of this polymorphism is not known, the high degree of nonconservative substitution, concentration to the putative ligand-binding site and recent observation that different MICA alleles bind to NKG2D with varying affinity has generated much interest. The MIC genes are attractive functional and positional candidate genes for inflammatory bowel disease susceptibility as a consequence of their position in the HLA region and expression on the gastrointestinal epithelium. We developed a robust, high-resolution PCR-SSP genotyping method that can be incorporated into the standard 'Phototyping' system and which effectively identifies 46 of 54 MICA alleles, and all 17 MICB alleles. We applied this system in combination with microsatellite genotyping of the exon 5 variable number of tandem repeats (VNTR) to the investigation of genetic susceptibility to the inflammatory bowel diseases, ulcerative colitis and Crohn's disease. We studied 248 patients with Crohn's disease, 329 with ulcerative colitis and 354 ethnically matched controls. Linkage disequilibrium patterns between HLA-B, MICA and MICB are presented. Analysis by individual allele or by multilocus haplotype failed to identify any significant disease associations.

Prognosis for dogs with nonlymphomatous, small intestinal tumors treated by surgical excision

Long-term follow-up information was obtained for 39 dogs that had undergone surgical excision of nonlymphomatous, small intestinal tumors. For all dogs evaluated in this study, the median survival time was 10 months, and the one- and two-year survival rates were 40.5% and 33.1%, respectively. There was no difference in survival times between dogs with adenocarcinomas (n=23) and dogs with leiomyosarcomas (n=16). Survival times were significantly (p less than 0.0001) shorter for dogs with histological evidence of metastases at the time of surgery (median, 3.0 months) than for dogs with no histiological evidence of metastases (median, 15.0 months).

Primary non-Hodgkin's lymphoma of the ovaries: imaging findings

Primary ovarian lymphoma is very rare. We report a case of primary ovarian Burkitt-type non-Hodgkin's lymphoma, describing the imaging appearance on ultrasound, CT and MRI, and review the literature.

Separation of the toxic and glutathione-enhancing effects of the naturally occurring nitrile, cyanohydroxybutene

Cyanohydroxybutene (CHB) is reported to be hepatotoxic in male Fischer 344 rats at an oral dose of 300 mg/kg and, while no longer hepatotoxic, pancreatotoxic at 200 mg/kg. In addition, the 200 mg/kg dose causes a persistent elevation in hepatic and pancreatic glutathione (GSH). This study was conducted to determine if smaller doses of CHB could cause GSH elevation in the absence of toxicity. A single oral dose of 100 mg/kg or multiple lower doses (50 mg/kg daily for 3 days or 30 mg/kg for 6 days) caused a significant and persistent increase in pancreatic GSH, although hepatic levels were unchanged. Ten milligrams per kilogram, even daily for 24 days, was without effect on hepatic or pancreatic GSH. Neither a single oral dose of 100 mg/kg nor multiple lower doses were associated with toxicity. However, when either 100 or 50 mg/kg were administered intravenously, pancreatic apoptosis was observed. In animals dosed with 100 mg/kg iv, mixed histiocytic and suppurative inflammation and frank pancreatic necrosis also developed and were associated with elevated plasma lipase and amylase. The animals receiving CHB intravenously also exhibited elevated GSH levels in both pancreas and liver. This study shows that oral doses between 30 and 100 mg CHB/kg can be used to elevate GSH levels without any pancreatotoxicity. However, a single 50 mg CHB/kg dose given intravenously causes apoptosis, while 100 mg/kg causes severe pancreatotoxicity with necrosis.

The oral examination: a study of academic and non-academic factors

The oral examination in psychiatry for final-year medical students at Wellington and Dunedin School of Medicine, University of Otago, was studied. Between December 1989 and April 1990, 40 medical students were videorecorded during such an examination. The transcripts of the recording of each oral, and at a later date the videorecordings, were individually scored by a panel of six research psychiatrists who were experienced examiners. In addition verbal and non-verbal behaviour was rated using visual analogue scales and the students completed personality and anxiety questionnaires. There was a low level of agreement between research psychiatrists in the allocation of oral marks. The oral score was positively associated with the level of confidence of the student and negatively with anxiety in men.

Behavioural determinants of COVID-19 vaccination acceptance among healthcare workers: a rapid review

OBJECTIVES

Vaccinating healthcare workers (HCWs) against COVID-19 has been a public health priority since rollout began in late 2020. Promoting COVID-19 vaccination among HCWs would benefit from identifying modifiable behavioural determinants. We sought to identify and categorize studies looking at COVID-19 vaccination acceptance to identify modifiable factors to increase uptake in HCWs.

STUDY DESIGN

Rapid evidence review.

METHODS

We searched MEDLINE and Cochrane databases until May 2021 and conducted a grey literature search to identify cross-sectional, cohort, and qualitative studies. Key barriers to, and enablers of, vaccine acceptance were categorized using the Theoretical Domains Framework (TDF), a comprehensive theoretical framework comprising 14 behavioural domains.

RESULTS

From 19,591 records, 74 studies were included. Almost two-thirds of responding HCWs were willing to accept a COVID-19 vaccine (median = 64%, interquartile range = 50-78%). Twenty key barriers and enablers were identified and categorized into eight TDF domains. The most frequently identified barriers to COVID-19 vaccination were as follows: concerns about vaccine safety, efficacy, and speed of development (TDF domain: Beliefs about consequences); individuals in certain HCW roles (Social/professional role and identity); and mistrust in state/public health response to COVID-19 (Social influences). Routinely being vaccinated for seasonal influenza (Reinforcement), concerns about contracting COVID-19 (Beliefs about consequences) and working directly with COVID-19 patients (Social/professional role and identity) were key enablers of COVID-19 vaccination among HCWs.

DISCUSSION

Our review identified eight (of a possible 14) behavioural determinants of COVID-19 vaccine acceptance among HCWs that, if targeted, could help design tailored vaccination messaging, policy, campaigns, and programs to support HCWs vaccination uptake.

Identifying behaviour change techniques in 287 randomized controlled trials of audit and feedback interventions targeting practice change among healthcare professionals

BACKGROUND

Audit and feedback (A&F) is among the most widely used implementation strategies, providing healthcare professionals with summaries of their practice performance to prompt behaviour change and optimize care. Wide variability in effectiveness of A&F has spurred efforts to explore why some A&F interventions are more effective than others. Unpacking the variability of the content of A&F interventions in terms of their component behaviours change techniques (BCTs) may help advance our understanding of how A&F works best. This study aimed to systematically specify BCTs in A&F interventions targeting healthcare professional practice change.

METHODS

We conducted a directed content analysis of intervention descriptions in 287 randomized trials included in an ongoing Cochrane systematic review update of A&F interventions (searched up to June 2020). Three trained researchers identified and categorized BCTs in all trial arms (treatment & control/comparator) using the 93-item BCT Taxonomy version 1. The original BCT definitions and examples in the taxonomy were adapted to include A&F-specific decision rules and examples. Two additional BCTs ('Education (unspecified)' and 'Feedback (unspecified)') were added, such that 95 BCTs were considered for coding.

RESULTS

In total, 47/95 BCTs (49%) were identified across 360 treatment arms at least once (median = 5.0, IQR = 2.3, range = 129 per arm). The most common BCTs were 'Feedback on behaviour' (present 89% of the time; e.g. feedback on drug prescribing), 'Instruction on how to perform the behaviour' (71%; e.g. issuing a clinical guideline), 'Social comparison' (52%; e.g. feedback on performance of peers), 'Credible source' (41%; e.g. endorsements from respected professional body), and 'Education (unspecified)' (31%; e.g. giving a lecture to staff). A total of 130/287 (45%) control/comparator arms contained at least one BCT (median = 2.0, IQR = 3.0, range = 0-15 per arm), of which the most common were identical to those identified in treatment arms.

CONCLUSIONS

A&F interventions to improve healthcare professional practice include a moderate range of BCTs, focusing predominantly on providing behavioural feedback, sharing guidelines, peer comparison data, education, and leveraging credible sources. We encourage the use of our A&F-specific list of BCTs to improve knowledge of what is being delivered in A&F interventions. Our study provides a basis for exploring which BCTs are associated with intervention effectiveness.

TRIAL REGISTRATIONS

N/A.

Reliability of the draft diagnostic criteria for research of ICD-10 in comparison with ICD-10 and DSM-III-R

The reliability and ease of use of DSM-III-R and the clinical and research versions of ICD-10 were assessed by 5 psychiatrists working in pairs. They diagnosed 60 patients. All 3 systems showed similar and high interrater and intersystem agreement for major diagnostic categories but not for subcategories. A number of implications of these results are discussed.

The transition from hospital to home following acute coronary syndrome: an exploratory qualitative study of patient perceptions and early experiences in two countries

OBJECTIVES

Following acute coronary syndrome (ACS), it is standard practice for stable patients to be discharged as quickly as possible from hospital. If patients are not adequately supported at this time, issues such as readmission can occur. We report findings from an exploratory qualitative study investigating the perceptions and early experiences of patients transitioning from hospitals in the UK and USA to home following ACS.

METHODS

Within 1 month of discharge, we conducted semi-structured telephone interviews with patients hospitalised for ACS (UK: n = 8; USA: n = 9). Data were analysed using the Framework Method.

KEY FINDINGS

We identified four superordinate themes. Coping, adjustment and management: Patients were still adjusting to the physical limitations caused by their event but most had begun to implement positive lifestyle changes. Gaps in care transition: Poor communication and organisation postdischarge resulted in delayed follow-up for some patients causing considerable frustration. Quality of care from hospital to home: Patients experienced varied inpatient care quality but had largely positive interactions in primary/community care. Pharmacy input during care transition was viewed favourably in both countries. Medication-taking beliefs and behaviour: Patients reported good initial adherence to treatment but side effects were a concern.

CONCLUSIONS

ACS patients experienced gaps in care early in the transition from hospital to home. Poor communication and uncoordinated support postdischarge negatively impacted patient experience. Further research is needed to determine how patients' early experiences following ACS can affect longer-term outcomes including healthcare engagement and treatment maintenance.

Identifying behaviour change techniques within randomized trials of interventions promoting deceased organ donation registration

OBJECTIVE

Increasing deceased organ donation registration may increase the number of available organs for transplant to help save lives. This study aimed to identify which behaviour change techniques (BCTs; or 'active ingredients') are reported within randomized trials of interventions promoting deceased organ donation registration and of those, which are associated with a larger intervention effect.

METHODS

We conducted a secondary analysis of 45 trials included in a Cochrane systematic review of deceased organ donation registration interventions. Two researchers used the BCT Taxonomy v1 to independently code intervention content in all trial groups. Outcome data were pooled and we used meta-regression to explore associations between individual and combinations of recurring BCTs and effect on registration intention and/or registration behaviour.

RESULTS

A total of 27 different BCTs (mean = 3.7, range = 1-9) were identified in intervention groups across the 45 trials. The five most common BCTs were: 'Information about health consequences' (71%); 'Instruction on how to perform the behaviour' (47%); 'Salience of consequences' (40%); 'Adding objects to the environment' (28%); and 'Credible source' (27%). Comparator groups in 20/45 trials also included identifiable BCTs (n = 12, mean = 3.1, range = 1-7). Meta-regression revealed that a combination of the three most common BCTs was associated with a larger intervention effect size for registration behaviour (k = 8, β = .19, p = .02).

CONCLUSIONS

Trials of deceased organ donation registration interventions focus predominantly on providing information, instruction, and a means to register. While potentially effective, a much wider set of possible BCTs could be leveraged to address known barriers to registration.

Interventions for increasing solid organ donor registration

BACKGROUND

A solution for increasing the number of available organs for transplantation is to encourage more individuals to register a commitment for deceased organ donation. However, the percentage of the population registered for organ donation remains low in many countries.

OBJECTIVES

To evaluate the benefits and harms of various interventions used to increase deceased organ donor registration.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 11 August 2020 through contact with an Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs), cluster RCTs and quasi-RCTs of interventions to promote deceased organ donor registration. We included studies if they measured self-reported or verified donor registration, intention to donate, intention to register a decision or number of individuals signing donor cards as outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed retrieved studies and extracted data from included studies. We assessed studies for risk of bias. We obtained summary estimates of effect using a random-effects model and expressed results as risk ratios (RR) (95% confidence intervals; CI) for dichotomous outcomes and mean difference (MD; 95% CI) or standardised mean difference (SMD; 95% CI) for continuous outcomes. In multi-arm trials, data were pooled to create single pair-wise comparisons. Analyses were stratified by specific intervention setting where available.

MAIN RESULTS

Our search strategy identified 46 studies (47 primary articles, including one abstract) comprising 24 parallel RCTs, 19 cluster RCTs and 3 quasi-RCTs. Sample sizes ranged from 138 to 1,085,292 (median = 514). A total of 16 studies measured registration behaviour, 27 measured intention to register/donate and three studies measured both registration behaviour and intention to register. Interventions were delivered in a variety of different settings: schools (14 studies), driver's motor vehicle (DMV) centres (5), mail-outs (4), primary care centres (3), workplaces (1), community settings (7) and general public (12). Interventions were highly varied in terms of their content and included strategies such as educational sessions and videos, leveraging peer leaders, staff training, message framing, and priming. Most studies were rated as having high or unclear risk of bias for random sequence generation and allocation concealment and low risk for the remainder of the domains. Data from 34/46 studies (74%) were available for meta-analysis. Low certainty evidence showed organ donation registration interventions had a small overall effect on improving registration behaviour (16 studies, 1,294,065 participants: RR 1.30, 95% CI 1.19 to 1.43, I2 = 84%), intention to register/donate (dichotomous) (10 studies, 10,838 participants: RR 1.21, 95% CI 1.03 to 1.42, I2 = 91%) and intention to register/donate (continuous) (9 studies, 3572 participants: SMD 0.23, 95% CI 0.11 to 0.36, I2 = 67%). Classroom-based interventions delivered in a lecture format by individuals from the transplant community may be effective at increasing intention to register/donate (3 studies, 675 participants: RR 1.33, 95% CI 1.15 to 1.55, I² = 0%). Community interventions targeting specific ethnic groups were generally effective at increasing registration rates (k = 5, n = 4186; RR 2.14, 95% CI 1.35 to 3.40, I² = 85%), although heterogeneity was high. In particular, interventions delivered in the community by trained peer-leaders appear to be effective (3 studies, 3819 participant: RR 2.09, 95% CI 1.08 to 4.06, I² = 87%), although again, the data lacked robustness. There was some evidence that framing messages (e.g. anticipated regret) and priming individuals (e.g. reciprocity) in a certain way may increase intention to register/donate, however, few studies measured this effect on actual registration. Overall, the studies varied significantly in terms of design, setting, content and delivery. Selection bias was evident and a quarter of the studies could not be included in the meta-analysis due to incomplete outcome data reporting. No adverse events were reported.

AUTHORS' CONCLUSIONS

In our review, we identified a variety of approaches used to increase organ donor registration including school-based educational sessions and videos, leveraging peer leaders in the community, DMV staff training, targeted messaging and priming. The variability in outcome measures used and incompleteness in reporting meant that most data could not be combined for analysis. When data were combined, overall effect sizes were small in favour of intervention groups over controls, however, there was significant variability in the data. There was some evidence that leveraging peer-leaders in the community to deliver organ donation education may improve registration rates and classroom-based education from credible individuals (i.e. members of the transplant community) may improve intention to register/donate, however, there is no clear evidence favouring any particular approach. There was mixed evidence for simple, low-intensity interventions utilising message framing and priming. However, it is likely that interest in these strategies will persist due to their reach and scalability. Further research is therefore required to adequately address the question of the most effective interventions for increasing deceased organ donor registration.

Healthcare provider-led interventions to support medication adherence following ACS: a meta-analysis

We conducted a systematic review and meta-analysis to determine the effectiveness of healthcare provider-led (HCPs) interventions to support medication adherence in patients with acute coronary syndrome (ACS). A systematic search of Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, IPA, CINAHL, ASSIA, OpenGrey, EthOS, WorldCat and PQDT was undertaken. Interventions were deemed eligible if they included adult ACS patients, were HCP-led, measured medication adherence and randomised participants to parallel groups. Intervention content was coded using the Behaviour Change Technique (BCT) Taxonomy and data were pooled for analysis using random-effects models. Our search identified 8870 records, of which 27 were eligible (23 primary studies). A meta-analysis (n=9735) revealed HCP-led interventions increased the odds of medication adherence by 54% compared to control interventions (k=23, OR 1.54, 95% CI 1.26 to 1.88, I2=57.5%). After removing outliers, there was a 41% increase in the odds of medication adherence with moderate heterogeneity (k=21, OR 1.41, 95% CI 1.21 to 1.65, I2=35.3%). Interventions that included phone contact yielded (k=12, OR 1.63, 95% CI 1.25 to 2.12, I2=32.0%) a larger effect compared to those delivered exclusively in person. A total of 32/93 BCTs were identified across interventions (mean=4.7, SD=2.2) with 'information about health consequences' (BCT 5.1) (19/23) the most common. HCP-led interventions for ACS patients appear to have a small positive impact on medication adherence. While we were able to identify BCTs among interventions, data were insufficient to determine the impact of particular BCTs on study effectiveness.

PROSPERO registration number

CRD42016037706.

Initial evaluation of a brief pharmacy-led intervention to modify beliefs about medicines and facilitate adherence among patients hospitalised with acute coronary syndrome

OBJECTIVES

Medication non-adherence is common among patients with acute coronary syndrome (ACS) and is associated with poor clinical outcomes. To date, pharmacists have been underutilised in the delivery of adherence interventions. Across two studies, we assessed the feasibility, acceptability and effectiveness of a novel pharmacy-led intervention for patients hospitalised with ACS.

METHODS

The theory-based intervention was comprised of two personalised sessions addressing perceptual (negative/erroneous treatment beliefs) and practical (suboptimal action planning) barriers to adherence. Study 1: A single-arm, feasibility and acceptability study was conducted to determine proof-of-concept. Pre-post-comparisons using the Beliefs about Medicines Questionnaire-Specific (BMQ-S) were made. Study 2: A non-randomised controlled before-after pilot study was conducted with the intervention delivered by a team of clinical pharmacists. Follow-up data were collected at 6 and 12 weeks post-discharge. Primary outcome measures included the BMQ-S and the Medication Adherence Report Scale 5.

RESULTS

Study 1: 15 patients received the intervention and reported higher BMQ-S necessity scores post-intervention. The intervention was deemed highly acceptable to patients; therefore, further testing was sought. Study 2: A total of 56 patients were recruited: control (n=29) versus treatment (n=27). At 6-week follow-up, the treatment group had higher BMQ-S necessity scores (M=21.8, SD=3.1) compared with control (M=19.8, SD=2.7; p=0.045), although this effect was not maintained at 12 weeks. No differences were reported in the other outcome measures.

CONCLUSIONS

Although the intervention was acceptable to patients, poor fidelity in delivery raises questions about its feasibility in practice. Furthermore, there was some impact on patients' beliefs about medications but no effect on adherence. These findings demonstrate the importance of conducting feasibility and acceptability studies when developing adherence innovations in clinical care. Future studies should consider enhancing the training process to ameliorate fidelity issues.

Exploring the experiences and perspectives of substitute decision-makers involved in decisions about deceased organ donation: a qualitative study protocol

INTRODUCTION

In Canada, deceased organ donation provides over 80% of transplanted organs. At the time of death, families, friends or others assume responsibility as substitute decision-makers (SDMs) to consent to organ donation. Despite their central role in this process, little is known about what barriers, enablers and beliefs influence decision-making among SDMs. This study aims to explore the experiences and perspectives of SDMs involved in making decisions around the withdrawal of life-sustaining therapies, end-of-life care and deceased organ donation.

METHODS AND ANALYSIS

SDMs of 60 patients admitted to intensive care units will be enrolled for this study. Ten hospitals across five provinces in Canada in a prospective multicentre qualitative cohort study. We will conduct semistructured telephone interviews in English or French with SDMs between 6 and 8 weeks after the patient's death. Our sampling frame will stratify SDMs into three groups: SDMs who were not approached for organ donation; SDMs who were approached and consented to donate and SDMs who were approached but did not consent to donate. We will use two complementary theoretical frameworks-the Common-Sense Self-Regulation Model and the Theoretical Domains Framework- to inform our interview guide. Interview data will be analysed using deductive directed content analysis and inductive thematic analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Centre Hospitalier de l'Université de Montréal Research Ethics Board. The findings from this study will help identify key factors affecting substitute decision-making in deceased organ donation, reasons for non-consent and barriers to achieve congruency between SDM and patient wishes. Ultimately, these data will contribute to the development and evaluation of tools and training for healthcare providers to support SDMs in making decisions about organ donation.

TRIAL REGISTRATION NUMBER

NCT03850847.

Improving patients' and staff's experiences of acute care

The aim of this audit was to assess the effect of the Quality Mark programme on the quality of acute care received by older patients by comparing the experiences of staff and older adults before and after the programme. Data from 31 wards in 12 acute hospitals were collected over two stages. Patients and staff completed questionnaires on the perceived quality of care on the ward. Patients rated improved experiences of nutrition, staff availability and dignity. Staff received an increase in training and reported better access to support, increased time and skill to deliver care and improved morale, leadership and teamwork. Problems remained with ward comfort and mealtimes. Overall, results indicated an improvement in ratings of care quality in most domains during Quality Mark data collection. Further audits need to explore ways of improving ward comfort and mealtime experience.

How do we leverage implementation science to support and accelerate uptake of clinical practice guidelines in transfusion medicine

BACKGROUND

Developing and disseminating clinical practice guidelines is a common strategy used to inform practice and address evidence-to-practice gaps that are prominent in transfusion medicine. Despite a highly systematic method for synthesizing evidence into guideline recommendations, comparatively little attention is paid to the real-world implementation of the recommendations in routine practice. A more scientific approach drawing on learnings from the field of implementation science is therefore warranted.

STUDY DESIGN AND METHODS

In this article, we propose a methodological roadmap to embed implementation science principles, frameworks, and methods to facilitate the development and uptake of transfusion medicine guidelines. We draw upon research undertaken in partnership with the International Collaboration of Transfusion Medicine Guidelines (ICTMG) to illustrate the roadmap in action.

RESULTS

The methodological roadmap constitutes five steps which have been matched to existing processes for developing and implementing clinical practice guidelines: (1) environmental scan; (2) detailing who needs to do what differently, per guideline recommendation; (3) barriers and enablers assessment; (4) tailoring implementation strategies to identified barriers and enablers; and (5) implementation and evaluation of implementation strategies. For each step, we define the key concepts and methods involved, and share examples from work done with ICTMG to support transfusion medicine guideline implementation.

DISCUSSION

We intend this methodological roadmap for clinicians, researchers, and organizations involved in supporting clinical practice guideline use. Informed by principles, frameworks, and methods from implementation science, the roadmap can provide a more structured, transparent, and replicable approach to improve the implementation of guideline recommendations in transfusion medicine.

Audit and feedback: effects on professional practice

BACKGROUND

Audit and feedback (A&F) is a widely used strategy to improve professional practice. This is supported by prior Cochrane reviews and behavioural theories describing how healthcare professionals are prompted to modify their practice when given data showing that their clinical practice is inconsistent with a desirable target. Yet there remains uncertainty regarding the effects of A&F on improving healthcare practice and the characteristics of A&F that lead to a greater impact.

OBJECTIVES

To assess the effects of A&F on the practice of healthcare professionals and to examine factors that may explain variation in the effectiveness of A&F.

SEARCH METHODS

With the Cochrane Effective Practice and Organisation of Care (EPOC) group information scientist, we updated our search strategy to include studies published from 2010 to June 2020. Search updates were performed on 28 February 2019 and 11 June 2020. We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Library, clinicaltrials.gov (all dates to June 2020), WHO ICTRP (all dates to February Week 3 2019, no information available in 2020 due to COVID-19 pandemic). An updated search and duplicate screen was completed on February 14, 2022; studies that met inclusion criteria are included in the 'Studies awaiting classification' section.

SELECTION CRITERIA

Randomised trials, including cluster-trials and cross-over and factorial designs, featuring A&F (defined as measurement of clinical performance over a specified period of time (audit) and provision of the resulting data to clinicians or clinical teams (feedback)) in any trial arm that reported objectively measured health professional practice outcomes.

DATA COLLECTION AND ANALYSIS

For this updated review, we re-extracted data for each study arm, including theory-informed variables regarding how the A&F was conducted and behaviour change techniques for each intervention, as well as study-level characteristics including risk of bias. For each study, we extracted outcome data for every healthcare professional practice targeted by A&F. All data were extracted by a minimum of two independent review authors. For studies with dichotomous outcomes that included arms with and without A&F, we calculated risk differences (RDs) (absolute difference between arms in proportion of desired practice completed) and also odds ratios (ORs). We synthesised the median RDs and interquartile ranges (IQRs) across all trials. We then conducted meta-analyses, accounting for multiple outcomes from a given study and weighted by effective sample size, using reported (or imputed, when necessary) intra-cluster correlation coefficients. Next, we explored the role of baseline performance, co-interventions, targeted behaviour, and study design factors on the estimated effects of A&F. Finally, we conducted exploratory meta-regressions to test preselected variables that might be associated with A&F effect size: characteristics of the audit (number of indicators, aggregation of data); delivery of the feedback (multi-modal format, local champion, nature of comparator, repeated delivery); and components supporting action (facilitation, provision of specific plans for improvement, co-development of action plans).

MAIN RESULTS

We included 292 studies with 678 arms; 133 (46%) had a low risk of bias, 41 (14%) unclear, and 113 (39%) had a high risk of bias. There were 26 (9%) studies conducted in low- or middle-income countries. In most studies (237, 81%), the recipients of A&F were physicians. Professional practices most commonly targeted in the studies were prescribing (138 studies, 47%) and test-ordering (103 studies, 35%). Most studies featured multifaceted interventions: the most common co-interventions were clinician education (377 study arms, 56%) and reminders (100 study arms, 15%). Forty-eight unique behaviour change techniques were identified within the study arms (mean 5.2, standard deviation 2.8, range 1 to 29). Synthesis of 558 dichotomous outcomes measuring professional practices from 177 studies testing A&F versus control revealed a median absolute improvement in desired practice of 2.7%, with an IQR of 0.0 to 8.6. Meta-analyses of these studies, accounting for multiple outcomes from the same study and weighting by effective sample size accounting for clustering, found a mean absolute increase in desired practice of 6.2% (95% confidence interval (CI) 4.1 to 8.2; moderate-certainty evidence) and an OR of 1.47 (95% CI 1.31 to 1.64; moderate-certainty evidence). Effects were similar for pre-planned subgroup analyses focused on prescribing and test-ordering outcomes. Lower baseline performance and increased number of co-interventions were both associated with larger intervention effects. Meta-regressions comparing the presence versus absence of specific A&F components to explore heterogeneity, accounting for baseline performance and number of co-interventions, suggested that A&F effects were greater with individual-recipient-level data rather than team-level data, comparing performance to top-peers or a benchmark, involving a local champion with whom the recipient had a relationship, using interactive modalities rather than just didactic or just written format, and with facilitation to support engagement, and action plans to improve performance. The meta-regressions did not find significant effects with the number of indicators in the audit, comparison to average performance of all peers, or co-development of action plans. Contrary to expectations, repeated delivery was associated with lower effect size. Direct comparisons from head-to-head trials support the use of peer-comparisons versus no comparison at all and the use of design elements in feedback that facilitate the identification and action of high-priority clinical items.

AUTHORS' CONCLUSIONS

A&F can be effective in improving professional practice, but effects vary in size. A&F is most often delivered along with co-interventions which can contribute additive effects. A&F may be most effective when designed to help recipients prioritise and take action on high-priority clinical issues and with the following characteristics: 1. targets important performance metrics where health professionals have substantial room for improvement (audit); 2. measures the individual recipient's practice, rather than their team or organisation (audit); 3. involves a local champion with an existing relationship with the recipient (feedback); 4. includes multiple, interactive modalities such as verbal and written (feedback); 5. compares performance to top peers or a benchmark (feedback); 6. facilitates engagement with the feedback (action); 7. features an actionable plan with specific advice for improvement (action). These conclusions require further confirmatory research; future research should focus on discerning ways to optimise the effectiveness of A&F interventions.

"Comfort of Sitting at Home While Getting Information I Needed": Experiences of Cardiac Patients Attending Virtual Cardiac Rehabilitation

Because of the COVID-19 pandemic, several health care services, including cardiac rehabilitation (CR), had to transition to virtual delivery, for which formal evaluations are lacking. In this pilot study, we investigated the implementation of a virtual CR program by surveying 30 patients attending virtual CR. Virtual CR was well received, although patients provided recommendations to improve delivery such as offering individual sessions and changing how education materials were delivered. Virtual delivery of CR likely has a role in health care, either independently or as part of a hybrid model; however, further evaluation is required.

The efficacy of using continuous glucose monitoring as a behaviour change tool in populations with and without diabetes: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Continuous glucose monitoring (CGM) holds potential as a precision public health intervention, offering personalised insights into how diet and physical activity affect glucose levels. Nevertheless, the efficacy of using CGM in populations with and without diabetes to support behaviour change and behaviour-driven outcomes remains unclear. This systematic review and meta-analysis examines whether using CGM-based feedback to support behaviour change affects glycaemic, anthropometric, and behavioural outcomes in adults with and without diabetes.

METHODS

Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Elsevier Embase, EBSCOhost PsycINFO, and ProQuest Dissertations & Theses Global were searched through January 2024. Eligible studies were randomised controlled trials in adults that implemented CGM-based feedback in at least one study arm compared to a control without CGM feedback. Dual screening, data extraction, and bias assessment were conducted independently. Mean differences in outcomes between intervention and comparison groups were analysed using generic inverse variance models and random effects. Robustness of pooled estimates from random-effects models was considered with sensitivity and subgroup analyses.

RESULTS

Twenty-five clinical trials with 2996 participants were included. Most studies were conducted in adults with type 2 diabetes (n = 17/25; 68%), followed by type 1 diabetes (n = 3/25, 12%), gestational diabetes (n = 3/25, 12%), and obesity (n = 3/25, 12%). Eleven (44%) studies reported CGM-affiliated conflicts of interest. Interventions incorporating CGM-based feedback reduced HbA1c by 0.28% (95% CI 0.15, 0.42, p < 0.001; I2 = 88%), and increased time in range by 7.4% (95% CI 2.0, 12.8, p < 0.008; I2 = 80.5%) compared to arms without CGM, with non-significant effects on time above range, BMI, and weight. Sensitivity analyses showed consistent mean differences in HbA1c across different conditions, and differences between subgroups were non-significant. Only 4/25 studies evaluated the effect of CGM on dietary changes; 5/25 evaluated physical activity.

CONCLUSIONS

This evidence synthesis found favourable, though modest, effects of CGM-based feedback on glycaemic control in adults with and without diabetes. Further research is needed to establish the behaviours and behavioural mechanisms driving the observed effects across diverse populations.

TRIAL REGISTRATION

CRD42024514135.

One size doesn't fit all: methodological reflections in conducting community-based behavioural science research to tailor COVID-19 vaccination initiatives for public health priority populations

BACKGROUND

Promoting the uptake of vaccination for infectious diseases such as COVID-19 remains a global challenge, necessitating collaborative efforts between public health units (PHUs) and communities. Applied behavioural science can play a crucial role in supporting PHUs' response by providing insights into human behaviour and informing tailored strategies to enhance vaccination uptake. Community engagement can help broaden the reach of behavioural science research by involving a more diverse range of populations and ensuring that strategies better represent the needs of specific communities. We developed and applied an approach to conducting community-based behavioural science research with ethnically and socioeconomically diverse populations to guide PHUs in tailoring their strategies to promote COVID-19 vaccination. This paper presents the community engagement methodology and the lessons learned in applying the methodology.

METHODS

The community engagement methodology was developed based on integrated knowledge translation (iKT) and community-based participatory research (CBPR) principles. The study involved collaboration with PHUs and local communities in Ontario, Canada to identify priority groups for COVID-19 vaccination, understand factors influencing vaccine uptake and co-design strategies tailored to each community to promote vaccination. Community engagement was conducted across three large urban regions with individuals from Eastern European communities, African, Black, and Caribbean communities and low socioeconomic neighbourhoods.

RESULTS

We developed and applied a seven-step methodology for conducting community-based behavioural science research: (1) aligning goals with system-level partners; (2) engaging with PHUs to understand priorities; (3) understanding community strengths and dynamics; (4) building relationships with each community; (5) establishing partnerships (community advisory groups); (6) involving community members in the research process; and (7) feeding back and interpreting research findings. Research partnerships were successfully established with members of prioritized communities, enabling recruitment of participants for theory-informed behavioural science interviews, interpretation of findings, and co-design of targeted recommendations for each PHU to improve COVID-19 vaccination uptake. Lessons learned include the importance of cultural sensitivity and awareness of sociopolitical context in tailoring community engagement, being agile to address the diverse and evolving priorities of PHUs, and building trust to achieve effective community engagement.

CONCLUSION

Effective community engagement in behavioural science research can lead to more inclusive and representative research. The community engagement approach developed and applied in this study acknowledges the diversity of communities, recognizes the central role of PHUs, and can help in addressing complex public health challenges.

Development and initial testing of an illness perception questionnaire for substitute decision makers of critically ill patients: a mixed methods study

PURPOSE

The Brief Illness Perception Questionnaire (Brief-IPQ) is used to quantify a patient's understanding of their condition. In critical care settings, substitute decision makers (SDMs) are tasked with making decisions on behalf of patients, but it can be difficult to evaluate how they perceive the patient's illness. We developed the Illness Perception Questionnaire for Substitute Decision Makers (IPQ-SDM) by adapting the Brief-IPQ and testing it with SDMs of patients in critical care.

METHODS

In a mixed methods study, we modified the Brief-IPQ for the context of SDMs of critically ill patients using qualitative feedback. We then approached SDMs of critically ill patients three days after intensive care unit (ICU) admission to complete the IPQ-SDM in a prospective observational study. We calculated summary statistics for the individual questions and the total score. We evaluated prespecified associations between individual questions as well as the total score with clinical data that were abstracted from the patient chart.

RESULTS

We received 44/50 (88%) complete responses with a mean (standard deviation [SD]) total score of 43 (11). Forty-six percent reported that they did not have any in-person visits due to the restrictions during the COVID-19 pandemic. The correlation of total score with the nine equivalents of nursing manpower score (NEMS) was 0.42 (P = 0.005) but it was not correlated (P = 0.07) with the multiple organ dysfunction score (MODS). The total mean (SD) score was higher (i.e., worse) for patients who died in hospital (48.2 [9.7], n = 13) than for those who were discharged alive (40.5 [10.2], n = 31, P = 0.03). Concern regarding the illness was correlated with MODS (Spearman correlation coefficient [ρ] = 0.39, P = 0.01) and NEMS (ρ = 0.29, P = 0.04).

CONCLUSION

We observed a modest level of correlation of the IPQ-SDM score with clinical measures in the adult ICU setting. Further research is needed before such a tool is broadly implemented.