Why don't physicians follow clinical practice guidelines? A framework for improvement

Stakeholders' Perspectives on Quality Measurement of Oral Health Care in the Netherlands: A Qualitative Study

OBJECTIVE

This study aimed to identify which barriers and facilitators exist and can be expected when measuring quality of oral health care according to different stakeholders in the Netherlands.

METHODS

A total of 36 semistructured interviews were conducted with dentists, patients, universities and knowledge institutes, health insurance companies, professional dental associations, and governmental health organisations. Using qualitative content analysis, barriers and facilitators were classified according to the frameworks of Grol and Cabana.

RESULTS

In total 70 barrier and 53 facilitating factors were identified in the 5 domains of the frameworks. Various stakeholders found quality measurement challenging because the quality of oral health care is difficult to define with a lack of consensus on what constitutes quality of oral health care. Patients mentioned that, for them, quality of oral health care is difficult to assess. Dentists experienced a fear of being monitored and were apprehensive of the administrative burden of quality measurement. On an organisational level, the isolation of dentistry from the medical field was mentioned as a barrier. Facilitating factors were discussing quality in a trusted environment, and developing more clinical practice guidelines, which include meaningful quality measures.

DISCUSSION

This study identified barriers and facilitators for measuring quality of oral health care in the Netherlands. Findings signal the importance of achieving consensus on the definition of quality of oral health care. Further strategy discussions about how quality of oral health care can be made insightful in a way acceptable to all stakeholders are needed to make progressions in quality improvement.

Concomitant use of clopidogrel and proton pump inhibitors: A retrospective analysis of prescription behaviour

AIMS

Since omeprazole and esomeprazole reduce the effect of clopidogrel on the inhibition of platelet aggregation, concomitant use of these drugs has been discouraged by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) since 2010. Currently, it is unknown how often this undesired drug-drug combination is prescribed. The aim of this article is to determine the proportion of patients using omeprazole or esomeprazole among patients using clopidogrel with gastroprotective drugs and to identify differences between these two groups with regard to patient characteristics and prescriber characteristics.

METHODS

This was a retrospective analysis of Dutch outpatient medication prescription records between 2015 and 2022. The database had a coverage of approximately 62% of all outpatient prescriptions dispensed in The Netherlands.

RESULTS

The proportion of patients using omeprazole or esomeprazole as gastroprotective drug in combination with clopidogrel declined from 19.7% to 8.7% between 2015 and 2022. The undesired drug-drug combination was more often prescribed by internists, to women and to patients with polypharmacy (using >10 drugs).

CONCLUSIONS

Although the proportion of patients using clopidogrel together with omeprazole or esomeprazole declined between 2015 and 2022, the undesired combination is still frequently prescribed in The Netherlands. Education about this drug-drug interaction for pharmacists and prescribers is needed since pharmacotherapeutic alternatives are available.

SAGES white paper on antibiotic omission in the management of acute uncomplicated diverticulitis: why, when, who, and most importantly, how

BACKGROUND

Historically, the management of acute uncomplicated diverticulitis was centered on antibiotics. However, modern theories regarding the pathogenesis of diverticulitis have challenged the notion that antibiotics are necessary in all cases. Despite major reform in many societal guidelines, the adoption of non-antibiotic therapy for uncomplicated diverticulitis has been limited, especially in North America. The purpose of this SAGES White Paper was to review the available evidence on antibiotic omission in uncomplicated diverticulitis and to explore methods of safe implementation.

METHODS

A task force within the SAGES Colorectal Surgery Committee was formed to work on this White Paper. The committee and its leadership approved an outline that would focus on the following topics: (1) Defining the problem with unnecessary antibiotic exposure; (2) Evaluating the evidence on antibiotic omission in uncomplicated diverticulitis; (3) Identifying the appropriate patient for antibiotic omission; (4) Outlining how to counsel patients who are treated without antibiotics; (5) Reviewing methods to safely implement this practice in both the hospital and community setting. These topics were divided up among members of the task force who performed a structured literature search in preparation for their assignments.

RESULTS

Antibiotics are associated with several patient and societal adverse effects, including the rising problem of antimicrobial resistance. Randomized controlled trials have demonstrated no superiority to the routine administration of antibiotics in acute uncomplicated diverticulitis. Appropriate patients for antibiotic omission include those who are immunocompetent, non-septic, and have mild symptoms/disease severity on imaging. Existing frameworks for the safe implementation of new practices can be referenced to help increase adoption of non-antibiotic therapy.

CONCLUSION

The existing body of evidence supports antibiotic omission in appropriate cases of acute uncomplicated diverticulitis. In order to increase the widespread adoption of this practice, buy-in from key stakeholders (both healthcare professionals and patients) is necessary.

Mental Health Provider Knowledge and Attitudes Toward Diagnosing Anxiety Disorders in the Veterans Health Administration

Clinical practice guidelines indicate treatments for specific anxiety diagnoses. Misdiagnosing specific anxiety disorders as unspecified anxiety may prevent patients from receiving appropriate care. Provider knowledge and attitudes may influence diagnostic practices. This study evaluated provider knowledge of diagnostic criteria for anxiety disorders and attitudes toward diagnostic processes and the relevance of diagnosis to patients' treatment. This qualitative analysis of interviews included 32 Veterans Health Administration providers in Primary Care Behavioral Health and Specialty Mental Health. Interview guides were created using a framework that outlines barriers regarding provider knowledge, attitudes, and behaviors as they pertain to following clinical practice guidelines. Most providers described themselves as familiar with diagnostic criteria for anxiety disorders and discussed consulting the Diagnostic and Statistical Manual of Mental Disorders if unsure about criteria. Providers were divided on the relevance of diagnostic specificity to a patient's treatment plan and outcomes. In the Veterans Health Administration, providers across different settings, roles, and tendency toward assigning specific diagnosis disagree on the relevance of diagnostic specificity for a patient's treatment and outcomes. Future research should seek to understand this divide and evaluate methods for optimizing a patient's likelihood of receiving a proper, accurate diagnosis.

Massive Hemorrhage Protocol adoption and standardization with a provincial toolkit: a follow-up survey of Ontario hospitals

PURPOSE

Massive Hemorrhage Protocols improve outcomes for adults with severe hemorrhage, yet only 65% of Ontario hospitals had implemented one by 2018. In response, a Massive Hemorrhage Protocol toolkit was developed and disseminated province-wide in 2021. This study compares Massive Hemorrhage Protocol adoption and content in Ontario hospitals in 2023 versus 2018 using a pre- and post-toolkit rollout survey.

METHODS

A 98-question survey was emailed to transfusion medicine laboratory directors or their delegate at 159 hospitals in 2023, 2 years after a provincial Massive Hemorrhage Protocol toolkit rollout that included a 1-day virtual symposium. Results were compared with the 2018 survey containing 82 identical core questions using Chi-square test, Fisher exact test, and Wilcoxon rank-sum nonparametric tests for quantitative data, and content analysis for qualitative data.

RESULTS

The 2023 survey achieved a 100% response rate (n = 159); most respondents (n = 156) were transfusion staff. Hospitals with a Massive Hemorrhage Protocol increased significantly from 65% (n = 150) in 2018 to 77% (n = 159) in 2023 (p = 0.02). Small transfusion hospitals (< 5000 red blood cell units transfused/year) saw an increase in Massive Hemorrhage Protocol adoption from 60 to 74% (p = 0.02). By 2023, 95% (n = 159) of hospitals had/were implementing a Massive Hemorrhage Protocol. However, gaps in alignment to evidence-based recommendations remained, including hypothermia monitoring (missing in 25% of Massive Hemorrhage Protocols) tranexamic acid dosing (missing in 19%), and quality metric tracking (missing in 55%). Pediatric content was absent in 45% of Massive Hemorrhage Protocols in health centers caring for children.

CONCLUSION

The provincial Massive Hemorrhage Protocol toolkit's dissemination was feasible and associated with increased adoption in Ontario hospitals. Two-years post rollout, 77% of provincial hospitals have Massive Hemorrhage Protocols in place. Opportunities remain to align contents with evidence-based recommendations and expand to remaining hospitals. This strategy could guide other jurisdictions to improve Massive Hemorrhage Protocol adoption and harmonize practices.

Quality improvement project to improve cardiovascular risk screening in patients with rheumatoid arthritis

SIGNIFICANCE AND BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease that is associated with an increased cardiovascular (CV) risk.Additional CV risk screening is advised in several national and international guidelines, but is performed inadequately. The CV risk screening in the Netherlands is performed by the general practitioner (GP).

PURPOSE

The aim of our project was to increase the CV risk screening of patients with RA, performed by the GP, from 46% to 65% of the selected patients of 40 years and older, within the time frame of our project (18 months).

CONTEXT

The project was carried out at the outpatient rheumatology clinic at Isala Zwolle, a large teaching hospital, in an area with 106 GP practices. Patients with RA, aged 40 years and older, who did not already participate in a cardiovascular risk management (CVRM) programme in general practice were included.

INTERVENTION

A multicomponent improvement strategy was developed and implemented. A prospective cohort follow-up study was performed, with measurements at T=0, 6, 12, 14, 16 and 18 months. The multicomponent strategy included patient education, a standard CVRM text in the electronic patient record (EPR) as a reminder, an educational meeting about CVRM in general practice for the rheumatologists and nurses, as well as feedback sessions with the rheumatologists, showing current data.

RESULTS

In our project, 784 RA patients were included. At time T=0, a CV risk analysis had been performed in the past 5 years in 46.4% of the patients with RA, who were not already participating in a CVRM protocol.This was significantly increased to 55.4% at 18 months in a prospective observational follow-up study. The primary goal, however, was not reached within the time frame of our project.

DISCUSSION

The availability of patient education cards and the feedback sessions with rheumatologists significantly contributed to the improvement. The implementation of an automatic standard text in the EPR, serving as an electronic reminder, did not perform as well as was anticipated.

Shared Decision-Making with the "Professionally-Driven Zone of Patient or Surrogate Discretion" Model and its Application in Acute Care

Shared decision-making ("SDM") has increased in acceptance and become a gold standard in medical decision-making over the last two decades. Despite this, there continues to be disagreement about several facets of SDM that many existing models or versions do not sufficiently address, including: that there is a lack of agreement about which version or model of SDM to utilize in practice; that there are practical limitations on when SDM ought to be utilized; that SDM may be required to use different "harm thresholds" when making decisions for patients who have lost decision-making capacity or competence, or for those who have never had such capacity in the first place; and that many existing models of SDM succumb to what is known as the "framing problem," among other concerns. Elsewhere, this author presented a model of SDM titled, the Professionally-Driven Zone of Patient or Surrogate Discretion (or, Professionally-Driven ZPSD) as a more comprehensive and defensible way forward. This article sets out to expand on the expected benefits of the model, and apply it to several case studies in the acute-care setting in order to demonstrate its functionality as a model of SDM.

Between heuristic and deliberative thinking: a multi-center qualitative study of physicians' decision-making in infection prevention practice

BACKGROUND

Application of standard infection prevention and control (IPC) measures is crucial to prevent hospital-acquired infections, but compliance by physicians is suboptimal. Interventions aimed to improve compliance are often generic and lack sustained effects. A better understanding of physicians' trade-offs regarding application of IPC and influences on their behavior is needed to develop effective behavior change interventions. We aimed to understand physicians' decision-making processes around application of IPC and the factors that influence their behavior.

METHODS

This qualitative study involved semi-structured interviews with 18 physicians and 7 nurses from five different hospitals in the Netherlands. Reflexive thematic analysis involved inductive coding followed by deductive analysis using mechanisms of action, including the Theoretical Domains Framework, that link to behavior change techniques.

RESULTS

We found heterogeneity in physicians' approaches to decision-making around application of IPC. Some physicians relied on heuristics, while others applied logical reasoning. The latter group made an autonomous assessment of the risks for infection associated with a situation and traded off the costs and benefits of IPC application. The decision was further influenced by personal beliefs about the value of IPC and a supporting physical and social environment. Eighteen out of 26 mechanisms of action underlying the influences on IPC behavior were matched to our results; most important are "memory, attention and decision processes", "behavioral cueing", "beliefs about consequences", "values", "norms", "social influences", "social learning/imitation" and "environmental context and resources". These findings suggest that interventions are most likely to be beneficial if these focus on developing heuristics, changing risk beliefs, using social norms and imitation and generating a supportive environment.

CONCLUSION

The heterogeneity in physicians' decision-making and autonomous risk assessment which is different from other healthcare professionals calls for tailored interventions targeting heuristic decision making, personal beliefs, social norms and the environmental context.

Initial Treatment and Referral Patterns for Acute Facial Palsy: Insights From Emergency Department Practices

OBJECTIVES

To investigate variations in Bell's Palsy treatment and referrals within the Emergency Department (ED), with a focus on sociodemographic and provider-related factors.

METHODS

A retrospective cohort review was performed including patients with a new diagnosis of Bell's Palsy or acute facial paralysis treated at a single, tertiary academic ED between 2017 and 2024. Management practices, including the use of steroids, antivirals, imaging, specialty consultations, and referrals, were evaluated across sociodemographic variables and provider types. Multivariable logistic regression was used to identify differences in management practices.

RESULTS

The final cohort comprised 887 patients. Of these, 82.1% received steroids, 57.7% received antivirals, and 57.3% underwent imaging. Hispanic patients were significantly less likely to receive imaging (OR 0.48, p = 0.006), whereas older patients were more likely to undergo imaging (OR 1.04, p < 0.001). Patients with Medicare and Medicaid insurance were less likely to receive bimodal therapy (steroids with antivirals) compared to private insurance holders (OR 0.30, p < 0.001 and OR 0.49, p < 0.001, respectively). Residents and fellows were more likely to obtain specialty consults (OR 2.51, p < 0.001) and imaging (OR 1.42, p = 0.043) than attending physicians. Nearly one third of patients received subspecialty consultation by neurology (26.0%), otolaryngology (6.2%), or plastic surgery (0.2%).

CONCLUSIONS

Despite increasing awareness regarding the treatment of acute facial palsy, this study reveals existing disparities in initial management by age, insurance status, race, and provider type. Efforts should focus on increasing provider awareness of treatment guidelines to standardize management protocols for improved care delivery and equity.

LEVEL OF EVIDENCE: 4

Using an in-situ Simulation Model to Identify Deviations from Guideline-Based Management of Pediatric Status Epilepticus in Community Emergency Departments

Background

Children with epilepsy are often presented to Community Emergency Departments (CEDs) for acute treatment of status epilepticus (SE). Timely medical management is imperative to prevent morbidity and mortality, and adherence to evidence-based guidelines improves outcomes for high stakes/low frequency events. Barriers to guideline adherent management in the CED setting are understudied; in-situ simulation (ISS) can be used to identify gaps in care for events such as pediatric SE.

Objective

The primary objective was to assess for deviations from evidence-based guidelines in the management of pediatric SE. A secondary objective was to explore potential barriers to practice within the evidence-based guidelines.

Methods

We conducted a prospective observational ISS pilot study examining representative CED teams caring for a simulated child in SE. The primary outcome was overall adherence to the pediatric SE guidelines as measured by 12 metrics: 5 non-pharmacologic (for example: delays in vital sign assessment, failure to time seizure) and 7 pharmacologic (for example: incorrect benzodiazepine dose, delay in benzodiazepine administration or escalation to antiseizure medication). Additional metrics including provider knowledge (recognition of status epilepticus) and resources (antiseizure medications stocked) were analyzed as process measures. We enrolled 4 interprofessional teams at 4 participating ED sites.

Results

Overall, 0 of the 4 teams adhered to all 12 metrics. A barrier to timely administration of benzodiazepines for two of the sites came from attempting IV access repeatedly. No team referenced an up-to-date treatment algorithm based on current evidence-based guidelines.

Conclusion

Standardized ISS scenarios identified variability in adherence to the pediatric SE guideline across a pilot sample of local CEDs. Barriers to guideline-adherent care occurred at both individual and systems levels. The study was limited in scope to 4 pilot sites.

Factors influencing the implementation and adherence to volume-based enteral feeding protocols in the critical care setting: A scoping review

OBJECTIVE

Delivery of enteral nutrition is an essential component of care for patients in the intensive care unit (ICU); however, patients only receive approximately 60% of prescribed enteral nutrition. Volume-based feeding (VBF) has been demonstrated as a safe and effective strategy to catch up for missed delivery of enteral nutrition. The aim of this review was to investigate factors influencing the adherence and implementation of VBF in the adult critical care and high-dependency unit settings to inform future implementation of VBF protocols in the ICU.

METHODS

Systematic searches of databases (MEDLINE, EMBASE, and Emcare) and grey literature repositories (TROVE, TRIP, CPG Infobase, WorldCat, and Google) were conducted to identify original research studies including adults admitted to the ICU, where VBF or catch-up feeding protocols were in place. Studies reporting on barriers, enablers, and acceptability or adherence to VBF protocols were included.

RESULTS

A total of 28 studies involving 7057 participants were eligible for inclusion, of which 19 were conducted in the USA, seven in Canada, one in the UK, and one in Australia. Factors enabling the implementation of VBF included management support, multidisciplinary team engagement, a project team, multimodal education, and communication strategies. Embedding the protocol into current work systems increased success. Barriers included a culture of deprioritising nutrition, safety concerns, staff turnover, and failure to embed the changes into work systems including the electronic medical record. VBF was considered acceptable to ICU staff; however, adherence to VBF protocols was variable (between 32.1% and 90%).

CONCLUSION

Successful implementation of a VBF protocol is enabled by strong project leadership, staff education, team engagement, and embedding VBF into current work processes. VBF is acceptable to staff; however, continuous education is recommended to sustain change in practice. Implementation of VBF should be considered as part of an "enhanced" feeding strategy in the ICU setting.

REGISTRATION

The protocol was developed and registered a priori on Open Science Framework on 8th August 2023 (https://doi.org/10.17605/OSF.IO/8DJKY).

Differences in content of care and outcomes between a clinical practice guideline adherent program and usual care for patellofemoral pain: A retrospective pilot study

BACKGROUND

Patellofemoral pain (PFP) is a common knee condition in young and active individuals that is managed with highly variable treatment strategies.

OBJECTIVE

To determine whether the length, number of visits, and content of physical therapy care for patients with PFP differ between a Clinical Practice Guidelines (CPG) adherent program and usual care. Additionally, the percentage of patients reporting clinically important improvements in patient-reported outcomes in each group was evaluated as an exploratory aim.

DESIGN

Retrospective analysis of clinical data.

SETTING

Military outpatient physical therapy clinics.

PATIENTS

Thirty-two patients who received CPG-adherent care and 46 patients who received usual care.

INTERVENTIONS

Patients in the CPG-adherent group were classified into overuse/overload, movement coordination deficits, muscle performance deficits, or mobility impairments subcategories based on CPG-recommended examination procedures and received the CPG-recommended interventions. Patients in the usual care group received interventions based on clinical expertise and organizational practice standards.

MAIN OUTCOMES MEASURES

Length of care, number of visits, and intervention content were used as primary outcomes. The Anterior Knee Pain Scale (AKPS), Defense and Veterans Pain Rating Scale (DVPRS), and Global Rating of Change (GROC) scores were used as secondary outcomes. These scores were extracted from routinely collected health data available in medical records; as a result, not all patients completed these outcomes during the follow-up time points because they were optional.

RESULTS

The number of physical therapy visits and percentage of patients receiving knee-targeted exercises, soft tissue mobility interventions, neuromuscular reeducation, patient education, patellar taping, and foot orthoses were greater in the CPG-adherent group compared to usual care (p < .05). Additionally, most patients in the CPG-adherent group reported clinically meaningful improvements in secondary outcomes: AKPS (1 month: 13/23; 3 months: 11/16), DVPRS (1 month: 11/20; 3 months: 8/14), and GROC (1 month: 14/22; 3 months: 11/16). In contrast, fewer than half of the patients in the usual care group reached clinically meaningful thresholds: AKPS (1 month: 1/17; 3 months: 3/8), DVPRS (1 month: 3/15; 3 months: 3/7), and GROC (1 month: 2/12; 3 months: 2/7).

CONCLUSION

The content of the CPG-adherent care was significantly different versus usual care and associated with meaningful changes in outcomes. Several CPG-recommended interventions appeared to be underused in usual care, underscoring the value of further CPG adoption.

[Use of long-acting triple therapy for chronic obstructive pulmonary disease (COPD) in practice: The ELETHON physicians' survey]

Gaps in optimal COPD management have been identified in clinical practice, with discrepancies between guideline recommendations and routine care. The reasons for such discrepancies are incompletely understood. The ELETHON survey aimed to identify physicians' attitudes towards general concepts of COPD management and, in particular, initiation of inhaled triple therapies.ELETHON was a nationwide cross-sectional survey with general practitioners (GP) and pulmonary specialists (PS) working in the ambulatory outpatient setting in Germany, using a structured 17-item questionnaire (single or multiple choice questions) addressing the topics of secondary prevention, exacerbation detection, strategies for therapy escalation, choice of inhaled triple therapies and evaluation of treatment benefits.Questionnaires filled by n=2028 GPs and n=371 PS were analyzed. In both groups, secondary prevention was deemed important in COPD care (GP/PS 76.4%/90.6%), with inhalation technique, vaccination status, and appropriate inhaled pharmacotherapy as key components. Activity/rehabilitation was rarely mentioned by GPs (48.3% vs. 84.5%). Exacerbations and symptomatic worsening were the main triggers for therapy escalation, but were not recorded in a structured way. "Hospitalization" and "≥2 ambulatory exacerbations" were mentioned most frequently as thresholds. Neither GPs nor PS measured eosinophils in the majority of patients. Fixed triple combinations were preferred, with availability of different treatment steps in the same device as important decision aid. Treatment success was evaluated by exacerbations, quality of life, symptoms, lung function and rescue medication use, while COPD Assessment Test (CAT) score was rarely used by GPs and PS.The ELETHON survey identified gaps in COPD management in Germany. While secondary prevention is deemed important, escalation of inhaled therapy is undertaken rather late, the reported importance of vaccinations does not match current quota in German COPD patients, and non-pharmacological measures are often unused. Exacerbation and symptom documentation is rather subjective, validated questionnaires and blood eosinophils are of minor relevance. These results provide evidence of barriers and hidden potentials towards optimization of routine ambulatory care for COPD patients in Germany.

Is there consensus on diagnostics and treatment in colonic diverticulitis? Results of international survey

BACKGROUND

Clinical guidelines (CGs) developed by expert communities benefit both the patient and the clinician. Meanwhile a considerable proportion of specialists are not familiar with or follow them in their daily practice. Colonic diverticulitis (CD) is the third most common cause of hospitalization among patients with gastrointestinal diseases and common indication for colon resection. Actual tactics for diagnosis and treatment of CD, as well as data on what influences its choice and how the decisions made agree with the existing CGs can be identified by anonymous surveys.

METHODS

An anonymous internet survey of surgeons and coloproctologists was conducted. Groups of questions included demographics of the respondents; self-esteem score; sources of guidance in decision-making; classification systems for CD; preferable diagnostic tests; management of CD; indications for elective surgery; and outcomes of surgical treatment and others (n = 17). The study was conducted in accordance with the CHERRIES criteria. The required minimum sample size was calculated as 377 participants.

RESULTS

The study involved 401 respondents from 9 countries: 76.1% were general surgeons and 14.5% were colorectal surgeons. Excellent or good knowledge of the problem was claimed by 82.8% of the colorectal vs 66.2% of the general surgeons (p = 0.013). In decision-making respondents were largely guided by their professional experience, methods adopted in their clinic and domestic CGs. General Surgeons more often chose tactics inconsistent with CGs than coloproctologists. The largest differences between subgroups were noted for awareness of the reversal of Hartmann's procedure, most common postoperative complications and indications for elective surgery.

CONCLUSION

Adherence to the existing CGs was poor, which entails significant variation in the approaches practiced by the respondents from different cohorts. There is no consensus on the aspects that are not yet covered in the CGs. Further research is needed to elucidate these gaps and update the guidelines accordingly.

Increasing Olanzapine Prescribing for Patients Undergoing Highly Emetogenic Chemotherapy

Importance

Olanzapine as part of a 4-drug antiemetic regimen is highly effective at preventing nausea and vomiting in patients receiving highly emetogenic chemotherapy (HEC). National prescribing rates of olanzapine in eligible patients have, however, remained persistently low.

Objective

To describe efforts to increase the guideline-concordant use of olanzapine in patients receiving HEC in a statewide oncology collaborative.

Design, Setting, and Participants

The Michigan Oncology Quality Consortium (MOQC) is a collaborative of Michigan-based oncology practices whose mission is to advance the care of patients with cancer and their caregivers through comprehensive, patient- and practice-led quality improvement initiatives. Participants were patients receiving HEC at 38 MOQC member practices during an initiative from 2019 to 2023 to improve guideline-concordant inclusion of olanzapine as part of a 4-drug antiemetic regimen in HEC prophylaxis.

Interventions

Interventions included performance audit and feedback to practices along with peer comparison, learning collaboratives of practices, education by experts at collaborative meetings, creation of patient-facing materials, and the addition of value-based reimbursement beginning in 2021. Measure performance was assessed using the American Society of Clinical Oncology's Quality Oncology Practice Initiative.

Main Outcomes and Measures

Proportion of patients receiving olanzapine for the first cycle of HEC as part of a 4-drug antiemetic regimen for chemotherapy-induced nausea and vomiting.

Results

Between 2019 and 2024, data were manually collected from the medical records of 8662 patients treated with HEC at 38 medical oncology practices at 71 sites across the state. Individual patient-level demographic data are not available from the QOPI database. For patients from years 2021 through 2024, the median (IQR) age was 62 (52-69) years; 4434 were female (65.5%); 814 were Black or African American (12.0%), 121 were Hispanic or Latino (1.8%), and 5385 were White (79.7%). The use of olanzapine as part of a 4-drug antiemetic increased from 7.2% in 2019 to 63.4% in 2024 (χ21 = 553.61; P < .001).

Conclusions and Relevance

In this quality improvement study of olanzapine prescribing in eligible patients, MOQC deployed quality improvement methods to increase the prescribing of olanzapine as part of a 4-drug regimen in patients receiving HEC, well above both the baseline and national levels of prescribing. This work suggests that efforts to improve patient care can be effective across diverse practice types, locations, and sizes in a statewide collaborative. Ongoing efforts include supporting change in those practices with low rates of prescribing and demonstrating the importance of this work for patient outcomes.

Improvement in Pediatric Resident Self-Efficacy and Documentation of Childhood Obesity Care with an Educational Intervention

OBJECTIVES

Childhood obesity is a public health crisis with increasing rates and long-term complications. Primary care providers are essential to address this concern; however, clinicians report inadequate training and self-efficacy.

METHODS

This educational study evaluated the impact of an obesity management curriculum on residents' self-efficacy and documentation. Three interactive educational sessions were presented. Residents rated their self-efficacy on caring for patients with obesity using a retrospective pre-post anchored response scale survey. Practice change was evaluated via chart review. Documentation of key history and treatment items was collected utilizing a standardized rubric over a 2-month period both before and after the education.

RESULTS

Post-education, self-efficacy ratings were higher compared to pre-education scores (p<0.0001). Chart review for 63 residents showed improvement in documentation of history and treatment items (p=0.026). Nutrition, activity, and sleep history elements improved in post-graduate level (PGY) 1 residents documentation compared to PGY2 (p<0.0001) and PGY3 residents (p=0.004). Documentation of treatment components including healthy habits counseling, SMART goals, lab testing, referrals, and follow-up increased among all PGY levels (p=0.036).

CONCLUSIONS

A primary care-based curriculum improved resident self-efficacy in caring for patients with obesity. Documentation of history and treatment items increased for all residents, with greatest improvement by PGY1 residents.

Enhancing standardization in anorectal manometry testing: the impact of a national position paper

BACKGROUND

The 2019 International Anorectal Physiology Working Group published the 'London Classification', providing recommendations for anorectal manometry (ARM) and balloon expulsion testing (BET). Despite this, the extent of guideline adoption in clinical settings was unclear. This study aimed to evaluate ARM and BET practices across Israel, identify deviations from these international guidelines, and measure the impact of a newly instated national position paper.

METHODS

In late 2020, gastroenterologists from 95% of Israeli centers performing ARM responded to a comprehensive 61-item survey. The survey highlighted discrepancies with international standards, prompting the formation of a national task force. This task force drafted a position paper incorporating international recommendations, followed by an educational course on ARM and BET. A subsequent survey assessed practice changes 1 year later.

RESULTS

Initial findings showed considerable variation in practices, including inconsistent application of the London classification, lack of standardized reference values, selective reporting on parameters like anal squeeze pressure, and differences in ARM and BET methodologies. Following the introduction of the position paper, 87% of centers altered their practices to include standardized reporting, consistent use of normal values, and uniform execution of tests like the rectoanal inhibitory reflex. Despite these improvements, variations in BET techniques persisted, particularly regarding balloon use and patient positioning.

CONCLUSION

The implementation of a national position paper and subsequent educational initiatives markedly enhanced the standardization of ARM and BET procedures in Israel, demonstrating the value of targeted educational and policy interventions in harmonizing medical practices with established international guidelines.

"It's Usually Not Dementia That's the Focus": Barriers and Facilitators of Dementia Care in Primary Care

BACKGROUND

Primary care provides most dementia care, yet providing high-quality dementia care within this setting remains a challenge. Medicare and health system initiatives create opportunities to improve quality of dementia care.

OBJECTIVE

To evaluate barriers and facilitators of high-quality dementia care in primary care with a secondary focus on interdisciplinary team-based primary care and health information technology.

DESIGN

Qualitative study using semi-structured interviews from July 2021 to January 2023.

PARTICIPANTS

Fifteen persons living with dementia (PLWD) and/or their 13 family caregivers, five primary care providers (PCPs), and 23 interdisciplinary primary care staff (nurses, medical assistants, care managers, social workers, pharmacists, practice administrators) across practices in a single health system.

APPROACH

We used qualitative content analysis to identify barriers and facilitators to dementia care within a framework of factors affecting whether clinicians follow clinical practice guidelines and how interdisciplinary teams and technology may support dementia care.

KEY RESULTS

Across all participants, there was limited knowledge of care practices and domains that constitute high-quality dementia care. Though PCP, staff, and caregiver attitudes were affected by their own prioritization of other medical conditions in primary care, all groups appreciated the importance of dementia care, and PCPs and staff were already addressing many relevant care domains. Barriers driving behavior were numerous and included time constraints, staffing challenges, and resource limitations in addition to patient or family-level factors. Interdisciplinary team-based care, telehealth, and patient portals can facilitate dementia care from PCP, staff, PLWD, and caregiver perspectives but interdisciplinary teams in particular are not yet used optimally.

CONCLUSIONS

PCPs, interdisciplinary staff, PLWD, and caregivers identify numerous barriers to high-quality dementia care. Implementing dementia care and primary care initiatives, optimizing interdisciplinary team functioning, patient portal and telehealth use for dementia care, PCP/staff dementia training, and addressing well-known primary care challenges could improve dementia care in select settings.

Implementation of mid-adult HPV vaccination guidelines into clinical practice

BACKGROUND

This study investigates the implementation of the 2019 U.S. guideline recommending shared clinical decision-making (SCDM) for HPV vaccination among mid-adults (ages 27-45) by health care providers.

METHODS

A quota sample of 600 health care providers serving mid-adults in the U.S. was surveyed on their practices regarding HPV vaccination and the implementation of the SCDM guideline. The survey collected descriptive statistics and conducted bivariate analyses.

RESULTS

Approximately 47 % of providers often or always engaged in shared clinical decision-making for HPV vaccinations, and 50 % offered the HPV vaccine, which significantly varied by provider type (p < 0.01). OB/GYNs had the highest frequency of always offering the vaccine (26 %), compared to family medicine (10 %) and internal medicine (12.5 %) providers. The major barriers identified were limited time (67 %) and perceived inadequate patient insurance coverage (65 %).

CONCLUSIONS

Despite approval of the shared clinical decision-making guideline for mid-adult HPV vaccination, implementation is inconsistent across different provider types, influenced by specific patient demographics. The identified barriers, including time constraints and insurance issues, impede uniform adoption of the guideline. Future initiatives should focus on tailored interventions for different provider disciplines to promote consistent and equitable health care delivery.

Paediatric resuscitation in regional Queensland: A simulation informed biopsy of current system challenges

OBJECTIVES

An outreach education service, Simulation Training Optimising Resuscitation for Kids (STORK) identified opportunities to use their course (Optimus PRIME) to understand and help optimise regional paediatric resuscitation. Our objective was to document challenges faced by healthcare providers in rural, remote, and regional (RRR) health centres in Queensland during a paediatric resuscitation course and ensure information reached stakeholders.

METHODS

Using in situ simulation, participants were prompted to identify real-life challenges during paediatric resuscitation. Participants co-generated solutions to these specific challenges and identified local advocates. Summaries for stakeholders included service strengths and improvement opportunities. Site follow-up identified actions taken and supported ongoing challenges.

RESULTS

Between March and December 2023, 40 Optimus PRIME courses were delivered. Thirty-nine course summaries were sent. Using the safety software in infusion pumps, 60% and 81% of sites were unable to correctly administer adrenaline or phenytoin, respectively. One or more pieces of paediatric oxygenation or ventilation equipment were lacking at 65% of sites. Participants working at 81% of sites were unfamiliar with the Queensland Health paediatric guidelines.

CONCLUSION

We highlight challenges for healthcare providers across Queensland and demonstrate educational teams can contribute to their resolution. Many problems perceived as local were occurring statewide. Our findings inform further advocacy. Our report informs opportunities for system optimisation and highlights inconsistencies in three key areas: infusion pump safety software, access to paediatric resuscitation equipment, and access to information technology. Statewide consistency synergising with local expertise is needed to ensure every child in Queensland has access to optimal resuscitation.

Clinician Characteristics Associated With Adoption of Updated National Colposcopy Guidelines

OBJECTIVE

To evaluate adherence to the 2019 ASCCP risk-based management consensus guidelines for management of patients following colpscopic cervical biopsy among US colposcopists.

METHODS

To elucidate factors associated with utilization of the 2019 guidelines for patients undergoing colposcopic cervical biopsy, the authors cross-sectionally surveyed physicians and advanced practice professionals who perform colposcopy. Clinicians responded to clinical vignettes describing scenarios for which management recommendations differed between 2019 and prior management guidelines. Vignette 1 involved deferral of repeat colposcopy for patients with a low-risk biopsy, HPV, and cytology results. Vignette 2 involved deferral of excisional treatment on a patient with repeated low-grade biopsy results. Binomial logistic regression models determined factors associated with utilization of 2019 guidelines.

RESULTS

A total of 670 colposcopists participated from across the United States. For Vignettes 1 and 2, guideline-adherent responses were given by 30.5% and 66.1% of participants, respectively. Colpsocopists practicing in community health centers were more likely to perform guideline-concordant care for Vignettes 1 and 2. Hispanic compared to non-Hispanic colposcopists and Internal or Family medicine compared to OB-GYN colposcopists are less likely to perform guideline-concordant care in Vignette 2. Irrespective of their chosen response, most believed they were guideline-adherent.

CONCLUSIONS

Many colposcopists may not realize their current management strategies are inconsistent with 2019 guidelines. Tailored education initiatives could address knowledge gaps, maximize patient benefits, and minimize harms.

A Mixed-Methods Study Examining Guideline-Concordant Colposcopy Practices Among a National Cohort of US Colposcopists

OBJECTIVES

The 2017 ASCCP Colposcopy Standards guidelines were designed to maximize the diagnostic yield of colposcopy. However, guideline adoption is often slow, and few studies have examined management of patients undergoing colposcopy.

METHODS

To elucidate factors associated with utilization of the 2017 ASCCP Colposcopy Standards guidelines for patients undergoing colposcopic cervical biopsy, the authors cross-sectionally surveyed and interviewed physicians and advanced practice providers who perform colposcopy. Clinicians responded to a clinical vignette describing a common colposcopy scenario. Clinicians were asked to describe where they would biopsy and why. Binomial logistic regression models determined factors associated with guideline concordance. Qualitative interviews further explored practice patterns.

RESULTS

A total of 671 colposcopists participated from across the United States. A total of 541 (81%) participants reported colposcopy practice concordant with the 2017 ASCCP Colposcopy Standards guidelines. A total of 490 (73%) participants reported that they were using the 2017 ASCCP Colposcopy Standards guidelines. Male colposcopists and those who were internal and family medicine clinicians were less likely to report guideline-concordant management than females and obstetrician-gynecologists. Colposcopists discussed the rationale behind guideline-concordant aspects of care, including taking targeted biopsies and using excisional rather than ablation procedures.

CONCLUSIONS

Most colposcopists perform biopsies and treatment consistent with the 2017 ASCCP Colposcopy Standards guidelines and understand the rationale behind multiple targeted biopsies.

Use of Statins for Primary Prevention Among Individuals With CKD in the United States: A Cross-Sectional, Time-Trend Analysis

RATIONALE & OBJECTIVE

Chronic kidney disease (CKD) populations face an elevated risk of cardiovascular disease (CVD), yet many remain undertreated with statins for primary prevention of CVD despite meeting eligibility criteria. We examined trends in statin use for primary prevention among individuals with CKD before and after the release of the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommending statin use for lipid management in selected adults with CKD.

STUDY DESIGN

Cross-sectional time-trend analysis.

SETTING & PARTICIPANTS

The 2001-2020 National Health and Nutrition Examination Survey (NHANES) data permitted identification of individuals eligible for statin therapy per the 2013 KDIGO guidelines based on (1) age≥50 without self-reported CVD; (2) CKD, defined as estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2 or albumin-creatinine ratio≥30mg/g; and (3) no dialysis in the previous 12 months.

OUTCOME

Statin use.

ANALYTICAL APPROACH

Poisson regression to estimate prevalence ratios (PR) comparing the periods before and after KDIGO guideline release and after accounting for NHANES's complex survey design and sampling weights.

RESULTS

Among eligible individuals, statin use approximately doubled from 18.6% in 2001-2002 to 36.1% in 2007-2008, increased modestly to 40.1% in 2013-2014, then subsequently plateaued. Multivariable analyses controlling for sociodemographic and clinical characteristics and secular trends demonstrated statin use for primary prevention was higher among the insured (PR, 2.48 [95% CI 1.66-3.69]), those with hypertension (PR, 1.49 [95% CI 1.28-1.74]), and those with diabetes (PR, 1.71 [95% CI 1.52-1.92]). Statin use was more common with lower eGFR (P=0.009) and higher body mass index (P=0.003) but did not differ by sex, race, or ethnicity.

LIMITATIONS

Statin use and CVD were self-reported, and our data did not capture statin intolerance nor patient-provider decision making information.

CONCLUSIONS

Statin use for primary prevention in CKD substantially increased before the 2013 release of KDIGO guidelines and subsequently plateaued. Use was higher among the insured and those with hypertension or diabetes.

PLAIN-LANGUAGE SUMMARY

Chronic kidney disease (CKD) affects many Americans, increasing their heart disease risk. Statins effectively reduce this risk in individuals with CKD but are underused. Our study examined statin use in individuals with CKD before and after the release of the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommending statin use for selected adults with CKD. It also examined factors influencing usage patterns. Using years of US National Health and Nutrition Examination Survey data, we found that while statin use doubled over the study period, fewer than half of eligible individuals with CKD received statins for primary prevention. Statin use was more common among those with health insurance, high blood pressure, or diabetes. This underuse highlights potential opportunities for improved risk monitoring and preventive use of statin therapy for individuals with CKD.

The evolution of teaching and learning regional anesthesia at every career stage: The U.S. perspective

Regional anesthesia and analgesia are integral to modern perioperative medicine and contribute to multimodal analgesia and enhanced recovery protocols. Over the past two decades, regional anesthesia practice has changed dramatically with the incorporation of real-time ultrasound guidance. Anesthesiologists in the U.S. who completed residency training in the early 2000s were not routinely taught how to use ultrasound for regional anesthesia, and subspecialty fellowships in regional anesthesia at that time were relatively few and varied widely in terms of educational experience. Today, the state of regional anesthesia education in the U.S. is completely different and has embraced a multipronged, multigenerational approach that addresses the needs of anesthesiologists in training, as well as anesthesiologists in practice throughout the career lifecycle. This review will cover the current state of regional anesthesia education for residents, fellows, and practicing anesthesiologists and will note important historical advances, as well as future trends that may shape the curricula for regional anesthesia learners in formal training and continuing education.

Locally adapted guidelines: a scoping review

BACKGROUND

Clinical practice guidelines (CPGs) often fail to be fully implemented in practice. One barrier to CPG implementation is inconsistency between recommendations and existing practice patterns. This can include patients, personnel, structure, availability of resources, cultural and ethical values. To account for this, it is feasible to tailor national CPGs to a regional or local context (e.g. hospital). Local ownership can be beneficial and help to implement the guideline without affecting guideline validity. This process is also known as guideline adaptation. We aimed to identify randomized controlled trials (RCTs) investigating the effectiveness of locally adapted CPGs.

METHODS

We performed a scoping review, following the JBI guidance. The scoping review was registered with the Open Science Framework ( https://osf.io/3ed2w ). The intervention had to be a locally adapted guideline (locally meaning adapted to any delineated area and/or entity at subnational and/or transnational level). Co-interventions were accepted. We did not restrict the control group. As we considered locally adapted guidelines as an intervention, and it seems feasible to test locally adapted guidelines in trials, we only considered RCTs, including cluster-RCTs. PubMed and Embase were searched in November 2024. Two reviewers independently screened titles and abstracts, full-text articles, and charted data. Conflicts were resolved by involving a third reviewer. Data were summarized descriptively. The findings were discussed with knowledge users.

RESULTS

Five cluster RCTs reported in 8 publications and published between 2000 and 2010, were included. The trials originated from the UK, Scotland, Australia, the US, and the Netherlands. The adapted CPGs focused on diabetes, asthma, smoking cessation, mental disorders, and menorrhagia and urinary incontinence. The number of sites (e.g. practices) ranged from 4 to 30. Reporting was mostly insufficient to understand how adaptation was performed. Interventions always included some form of dissemination, such as educational meetings or workshops.

CONCLUSIONS

There is a lack of RCTs investigating the effectiveness of locally adapted guidelines. A systematic review is unwarranted due to the clinical and methodological heterogeneity of these trials. The identified studies were largely conducted over 20 years ago, highlighting a significant knowledge gap. The reasons for the lack of similar studies today are unclear, which is surprising given advances in adaptation frameworks in guideline development. As the importance of contextualization is emphasized, future studies on locally adapted guidelines should be conducted with strong rationale supported by local data. Without a sound rationale, there is a risk that evidence-based, high-quality guidelines could be undermined. In future trials, authors should closely adhere to reporting guidelines.

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/3ed2w .

User perceptions of surgical antimicrobial prophylaxis guidelines in orthopaedic surgery in a tertiary Australian hospital

BACKGROUND

Surgical antimicrobial prophylaxis remains the most common indication for antimicrobial use in Australian hospitals. Despite efforts to improve practice, adherence to guideline recommendations continues to be suboptimal across surgical disciplines, including orthopaedics. The Therapeutic Guidelines: Antibiotic v16 currently advocates for single dose prophylaxis for open reduction internal fixation (ORIF) procedures. Audits undertaken in one Australian tertiary hospital have identified low levels of adherence to this recommendation. It is unclear as to why guidelines are not adhered to in this setting.

AIM

To understand the factors that influence multidose prescribing for ORIF procedures and the barriers and enablers to guideline use in an Australian tertiary hospital.

MATERIALS AND METHODS

Interviews (focus groups and one-on-one sessions) were held with orthopaedic surgeons (consultants), orthopaedic registrars, pharmacists, and anaesthetists from a tertiary public hospital in Australia. The Theoretical Domains Framework (TDF) was used to analyse results.

RESULTS

Six focus groups and three one-on-one interviews were conducted. Data were mapped to 12 TDF domains. Although clinicians were aware of guideline recommendations, this alone did not encourage the use of single dose prophylaxis. The decision to prescribe postoperative antibiotics was influenced by a combination of patient and environmental factors as well as fear of infection development. The lack of guideline specificity was commonly highlighted as a barrier to guideline use, as well as lack of agreement with guideline content. Enablers to guideline use included education that was targeted and repetitive, as well as improved dissemination of guidelines.

CONCLUSION

There are myriad factors that influence the decision to prescribe postoperative antibiotics for ORIF procedures. By understanding the social and cultural context of a local setting and the barriers and enablers that pertain to an environment, interventions can be developed to enhance guideline use, thereby improving antimicrobial prescribing.

Impact of Lipid-Lowering Combination Therapy With Statins and Ezetimibe vs Statin Monotherapy on the Reduction of Cardiovascular Outcomes: A Meta-analysis

OBJECTIVE

To evaluate the efficacy of combination lipid-lowering therapy (LLT) compared with statin monotherapy for low-density lipoprotein cholesterol (LDL-C) reduction, associated adverse events, and outcomes.

METHODS

A systematic literature search was conducted using PubMed, Embase, and ClinicalTrials.gov to identify relevant articles published from inception until the end of June 2024. The outcomes were assessed using pooled odds ratios (ORs) for categorical data and mean difference for continuous data, with corresponding 95% CIs.

RESULTS

A total of 14 studies (11 randomized controlled trials and 3 cohort studies) with 108,373 very high-risk patients were included in the final analysis. The mean age of the patients in the combination LLT group and the statin monotherapy group was 67.31 and 67.89 years, respectively. Pooled analysis revealed that combination LLT significantly more effectively reduced the LDL-C level from baseline (mean difference, -12.96 mg/dL; 95% CI, -17.27 to -8.65; P<.001) and significantly reduced all-cause mortality (OR, 0.81; 95% CI, 0.67 to 0.97; P=.02), major adverse cardiovascular events (OR, 0.82; 95% CI, 0.69 to 0.97; P=.02), and stroke incidence (OR, 0.83; 95% CI, 0.75 to 0.91; P<.001), with an insignificant effect on cardiovascular mortality (OR, 0.86; 95% CI, 0.65 to 1.12; P=.26) when compared with statin monotherapy. The risk of adverse events and the therapy discontinuation rate were comparable between groups.

CONCLUSION

Combination LLT was associated with an overall greater reduction in LDL-C, the same risk of adverse effects, and significantly lower risk of all-cause mortality, major adverse cardiovascular events, and stroke compared with statin monotherapy. Forthcoming guidelines should consider the lipid-lowering combination therapy as early as possible, preferably up-front, for more effective LDL-C goal achievement and significant reduction of cardiovascular disease outcomes and mortality in high- and very high-risk patients.

Examining human-AI interaction in real-world healthcare beyond the laboratory

Artificial Intelligence (AI) is revolutionizing healthcare, but its true impact depends on seamless human interaction. While most research focuses on technical metrics, we lack frameworks to measure the compatibility or synergy of real-world human-AI interactions in healthcare settings. We propose a multimodal toolkit combining ecological momentary assessment, quantitative observations, and baseline measurements to optimize AI implementation.

Healthcare Professionals' Knowledge, Attitudes, and Practices Towards Stem Cell Therapy for Sarcopenia: A Cross-Sectional Study in Beijing

Background

Sarcopenia significantly impacts the aging population, and this study investigates healthcare professionals' knowledge, attitudes, and practices (KAP) towards stem cell therapy for sarcopenia.

Methods

A cross-sectional study was conducted between January 1, 2024, and March 10, 2024, in medical institutions across Beijing. The study included healthcare professionals aged 18-70 years who completed a self-designed KAP questionnaire (Cronbach's α=0.917). Positive KAP was defined as scoring above 80% of the total score for each dimension.

Results

A total of 451 healthcare professionals participated in the study, with 66.7% female and 41.0% aged 40-49 years. The knowledge, attitude, and practice were 18.00 [10.00, 24.00] (possible range: 12-24), 25.00 [23.00, 30.00] (possible range: 6-30), and 21.00 [16.00, 30.00] (possible range: 7-35), respectively. Of these respondents, 13.7% were healthcare workers in the geriatrics department, who had a positive knowledge score of 22.00 [14.00, 24.00] and a positive attitude score of 29.50 [24.00, 30.00], but their practice scores remain moderate at 27.00 [20.00, 35.00]. Additionally, 140 (31.0%) had treated sarcopenia patients within six months and 277 (61.4%) were employed at public tertiary hospitals with positive knowledge. Multivariate logistic regression indicated that not having treated patients with sarcopenia in the past six months was independently associated with poor knowledge (OR = 0.30, 95% CI: [0.15, 0.62], p = 0.001). Mediating effect analysis showed that knowledge directly affected both attitude (β = 0.475, p < 0.001) and practice (β = 0.127, p = 0.004), and indirectly influenced practice through attitude (β = 0.296, p < 0.001).

Conclusion

Healthcare professionals exhibited inadequate knowledge, positive attitudes and inactive practices towards stem cell therapy for sarcopenia. Disease-related healthcare has positive knowledge, but moderate practice. Educational programs are essential to improve knowledge and foster proactive practices among healthcare professionals regarding stem cell therapy for sarcopenia.

Factors associated with clinician adherence to guidelines for postpartum care: results from a California survey

BACKGROUND

In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued multiple recommendations to optimize care within the first 12 weeks postpartum. We explored the extent to which clinicians follow ACOG's recommendations at the first postpartum visit and identified factors associated with overall adherence to clinical recommendations.

METHODS

Between September 2023 and February 2024, we collected data from an online survey about the care practices of 174 obstetric clinicians practicing in California. The response rate was 76%. Adherence was measured by asking the extent to which clinicians always complete care components drawn from a list of 26 of ACOG's clinical recommendations. We used descriptive statistics and ran linear regression models to quantify the association between adherence to guidelines and years of clinical practice, proportion of patients utilizing Medi-Cal, the method of reimbursement received by the provider, perceived organizational, financial and patient barriers, duration of the visit and number of collaborations with other providers.

RESULTS

The median percentage of components checked by clinicians was 62%. Significantly higher adherence was found among clinicians with at least 12 years of practice compared with those with approximately 5 years or less and among clinicians who collaborated with 5 or more multidisciplinary providers versus fewer than 3. Adherence was also higher among clinicians who on average spent at least 30 min vs. less than 20 min with their patients and those who perceived high financial barriers to care among their patients. In contrast, clinicians who served highly mixed practices of Medi-Cal and non-Medi-Cal recipients reported lower adherence.

CONCLUSION

We sought to understand which clinicians were more able to align their practice with ACOG guidelines at the first postpartum visit. We found that more experienced clinicians, those who simplified their practices to either all Medi-Cal or few Medi-Cal recipients, and those who collaborated more with other providers from various disciplines were best able to provide the care recommended in the guidelines. Our findings highlight where policy, resources and training are needed to improve guideline adherence and whole person care.

Real-world treatment patterns and outcomes based on RAS/BRAF status in metastatic colorectal cancer-Analysis of the Prospective Dutch Colorectal Cancer cohort

The treatment landscape for metastatic colorectal cancer (mCRC) has evolved into a continuum of care with an essential role for biomarkers and molecular subgroups. Treatment guidelines are primarily based on trial results; however, populations and outcomes differ from clinical practice. To support the interpretation of trial results and to assist in tailored patient counseling, we evaluated real-world treatment patterns and outcomes according to RAS/BRAF status. We included all patients diagnosed with BRAFV600E-mutated mCRC in 2015-2020, participating in the Prospective Dutch Colorectal Cancer cohort study, plus a 1:2 random selection of patients with RAS-mutated and double wild-type mCRC. We evaluated differences in administered lines of treatment (LOTs), local treatment, attrition rates, treatment duration, progression-free survival (PFS) and overall survival (OS). 178 BRAFV600E-mutated, 221 RAS-mutated, and 174 double wild-type patients were included. Of BRAFV600E-mutated patients, 26% received ≥3 LOTs, compared to 42% and 47% of the RAS-mutated and double wild-type patients, respectively (p = .002). Local treatment was performed in 25% of BRAFV600E-mutated, 43% of RAS-mutated, and 49% of double wild-type patients (p < .001). Median OS from diagnosis was 15.4, 24.1, and 32.6 months, respectively (p < .001) and loss of prognostic value of RAS/BRAF was observed from the 3rd LOT onwards (p = .17 and p = .54). This paper provides a comprehensive overview of the treatment landscape of mCRC per RAS/BRAF status in daily clinical practice. The observed substantial treatment heterogeneity within and between molecular subgroups underlines the importance of collecting real-world data to address post-trial knowledge gaps and to optimize individualized counseling for all mCRC patients.

Demand for cardiopulmonary resuscitation and bleeding control skills training in an urban region: a feasibility review of a community engagement effort

In this community engagement feasibility review, we evaluate the infrastructure warranted to implement bystander CPR and bleeding control skills training to diverse social organizations in an urban region over an 9-month period. Further, we review the necessary variables to sustain such an effort, for both the health system as well as the partnering communities. The intervention, brought forth with partnering communities through community health workers or other community brokers, for this community engagement feasibility study is the execution of teaching CPR skills and bleeding-control skills to various social networks in an urban region. The intervention focused on a changeable behavior, specifically on community members' abilities to execute life-saving interventions. The goal is to meet the intended behavior outcome under ideal circumstances, which are training of the aforementioned skills in respective community settings over a 120-min teaching session. Over an 9-month period, we were able to implement CPR training at 5 communities reaching 136 community members. These trainings were implemented in regions that have the highest homicide rates (mean of 0.86 ± 0.14 homicides per 1,000 persons; Maryland as a state averages 0.12). Implementation of CPR and bleeding control training in diverse community settings in an urban region was feasible and cost-efficient over a 9-month period. Further, utilizing community liaisons, such as community health workers, was critical to its success.

Barriers and Facilitators for Bringing Model-Informed Precision Dosing to the Patient's Bedside: A Systematic Review

Model-informed precision dosing (MIPD) utilizes mathematical models to predict optimal medication doses for a specific patient or patient population. However, the factors influencing the implementation of MIPD have not been fully elucidated, hindering its widespread use in clinical practice. A systematic review was conducted in PubMed from inception to December 2022, aiming to identify barriers and facilitators for the implementation of MIPD into patient care. Articles with a focus on implementation of MIPD were eligible for this review. After screening titles and abstracts, full articles investigating the clinical implementation of MIPD were included for data extraction. Of 790 records identified, 15 publications were included. A total of 72 barriers and facilitators across seven categories were extracted through a hybrid thematic analysis. Barriers comprised limited data for model validation, unclear regulatory pathways for model endorsement and additional drug level measurements required for certain types of MIPD. Facilitators encompassed the development of user-friendly MIPD tools continuously updated based on user feedback and data. Collaborative efforts among diverse stakeholders for model validation and implementation, along with education of end-users, may promote the utilization of MIPD in patient care. Despite ongoing challenges, this systematic review revealed various strategies to facilitate the clinical implementation of MIPD.

Error Traps in Developing a Pediatric Enhanced Recovery After Surgery (ERAS) Program

Enhanced recovery after surgery (ERAS) pathways have been shown to improve patient outcomes, increase patient satisfaction, and decrease costs. First created and implemented in the adult population, these pathways are now commonplace and continue to expand in the pediatric realm. While there are many proven benefits to ERAS pathways, there continue to be challenges to their proper implementation and long-term success. This article aims to explore common challenges in pediatric ERAS development and implementation, along with strategies to avoid potential pitfalls. Key themes include departmental and institutional support, stakeholder engagement, awareness of pathways, data management and dissemination, and long-term maintenance including Plan-Do-Study-Act (PDSA) cycles. Pathway development teams should be aware of these considerations and potential pitfalls, and focusing on them can promote long-term success for a well-designed pathway.

Intensive Home Blood Pressure Lowering in Patients With Advanced CKD

RATIONALE & OBJECTIVE

Optimal blood pressure (BP) targets in advanced chronic kidney disease (CKD) are controversial. More intensive BP lowering in the setting of advanced CKD is thought to be associated with risk of acute kidney injury, hyperkalemia, and end-stage kidney disease. We conducted a pilot trial of intensive BP control to determine if lower home systolic BP (SBP) targets can be safely achieved for patients with CKD through titration of BP medications using in-home measured BP.

STUDY DESIGN

Nonblinded randomized controlled trial.

SETTING & PARTICIPANTS

108 patients with advanced CKD (estimated glomerular filtration rate≤30mL/min/1.73m2) and hypertension.

INTERVENTIONS

Participants were randomized either to a target SBP goal of<120mm Hg (N=66) or a less intensive SBP goal (N=42). Antihypertensive medications were titrated to achieve the target home SBP range in the first 4 months of the study and maintained until the end of the study. Home BP was measured using a wireless Bluetooth-enabled monitor that transmitted readings to providers in real-time.

OUTCOME

The primary efficacy outcome was the difference in achieved clinic SBP between the 2 study arms from months 4-12. Safety outcomes included hyperkalemia, a composite outcome of falls or syncope, and onset of need for dialysis or kidney transplantation.

RESULTS

The mean clinic SBP at month 12 was 124.7mm Hg in the intensive SBP group versus 138.2mm Hg in the less intensive SBP group. Averaged over months 4-12, the achieved mean clinic SBP in the intensive SBP arm was 11.7mm Hg ([95% CI, 7.5-16], P<0.001), lower than the mean SBP achieved in the less intensive SBP arm. Primary safety outcomes were not statistically significantly different between the 2 arms (all P>0.05).

LIMITATIONS

Small sample size, which may have limited our ability to detect clinically significant differences in rates of adverse outcomes, and single-center design.

CONCLUSIONS

A clinic SBP goal of<120mm Hg is feasible to achieve with the help of real-time home BP monitoring and appears to be safe in this study population with advanced CKD. Larger trials to determine optimal BP targets in advanced CKD and the risks and benefits associated with more intensive BP control are warranted.

FUNDING

Grant from an educational institution (UCSF Research Allocation Program award).

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT02975505.

PLAIN-LANGUAGE SUMMARY

We conducted a pilot trial to test the feasibility of lowering blood pressure (BP) intensively through the use of home BP monitoring in patients with low kidney function. We found that home BP monitoring used to guide antihypertensive medication dosing permitted better BP control for patients with chronic kidney disease and did not appear to be associated with major adverse events.

Operation Rate for Displaced Distal Radius Fractures in the Elderly Decreased by 68% After the Implementation of Evidence-Based Practice

Background The increasing demand for orthopedic trauma surgery resources highlights the need for an efficient approach to implementing scientifically based interventions and de-implementation of interventions already in use that have been found no better than non-surgical treatments. Several factors have been identified as barriers or facilitators for translating evidence into clinical practice and behavioral changes. To facilitate a structured approach to applying these factors, we have adapted the generic theoretical domains framework (TDF) into the "CEBO model," providing a practical framework for implementing evidence in clinical decision-making in the hospital department of Zealand University Hospital, Koege, Denmark. Aim This study aims to evaluate the feasibility of the CEBO model for facilitating surgeon behavior change in an orthopedic surgery department. We will present clinical decision-making regarding the treatment of dorsally displaced distal radius fractures (DDDRF) in the elderly as an example. Methods Our department's standard of care for DDDRF in the elderly was surgical treatment. Under the evolving body of evidence, the CEBO model was applied to facilitate change in treating surgeons' behavior toward the increased use of non-surgical care. Following the four steps of the CEBO model, 1) leadership support was obtained, and relevant evidence was disseminated to all colleagues across the department; 2) stakeholders were invited to a symposium discussing best evidence and future practice; 3) conclusions from the symposium were summarized in a local clinical guideline stating non-surgical treatment as a new department standard and 4) to monitor the changes in treatment, patient charts were retrospectively reviewed from one year before and after the application of the CEBO model. Results In the first period, 95 of 120 (79%) were surgically treated, compared to 16 of 146 (11%) in the second period. An absolute decrease in the operation rate of 68% was observed. Conclusion We found the CEBO model highly feasible for facilitating surgeon behavior change in our orthopedic surgery department. Future studies will investigate the model's feasibility in other institutions and compare it to other behavior-targeted interventions.

Implementation of guideline-based lipid reporting and rate of lipid lowering therapy prescription

Lipid goal attainment remains suboptimal due to patient, provider, and system level factors. We aimed to assess whether updated, guideline-based lipid reporting and clinical decision support was associated with different lipid-lowering therapy (LLT) prescription patterns. We conducted a retrospective study in our electronic health record (EHR) comparing prescriptions within 90 days of lab reporting both prior to the reporting change (21,417 patients in 2019-2020) and after (39,866 patients in 2020-2021). We found a significant increase in the initiation of LLT in patients > 40 years of age with low-density lipoprotein cholesterol (LDL-C) ≥ 100  mg/dL, with 2377 (11.6%) initiated prior to compared to 6205 (16.3%) after the reporting change (P < .001). Among 4469 adult patients with atherosclerotic cardiovascular disease and LDL-C ≥ 70 mg/dL prior to (n = 2040) and after (n = 3277) the reporting change, there was a significantly higher rate of LLT initiation, 444 (25.9%) prior to vs 875 (31.8%) after; P < .001. In conclusion, after implementation of updated guideline-based lipid test reporting, we observed higher initiation rates of LLT for indicated patients. Our study suggests that guideline-based reporting of lipid test results may aid in guideline implementation.

Knowledge, attitude, and practice in communication assessment of speech-language pathologists working with adolescents with mental health concerns

PURPOSE

The recovery model underlying mental health services emphasises the importance of the voice of the adolescent client in identifying needs, goals, and negotiating intervention. This study aimed to characterise speech-language pathologists' (SLPs) knowledge, attitude, and practice in relation to communication assessment of adolescents, focusing on adolescents with mental health concerns and the use of discourse sampling and analysis.

METHOD

An online survey using a Knowledge, Attitude, Practice framework gathered data from 43 English-speaking SLPs. SLPs responded, using a five-point Likert scale, to closed statements regarding perceived knowledge, attitude, and practice in approaches to communication assessment. Survey items relating to discourse sampling and analysis were aggregated into subscales and six statements related to assessment of adolescents with mental health concerns. A final, open-ended question invited comments on changing clinical practice.

RESULT

A strong positive correlation was found between knowledge and practice; with a weak, positive correlation between knowledge and attitude.

CONCLUSION

SLPs are aware of the benefits of a comprehensive communication assessment. However, greater knowledge and experience is needed to incorporate more formalised approaches into clinical practice, especially as it relates to social and emotional outcomes. Participants' comments suggest that professional learning communities may be helpful in delivering this outcome.

Design of a clinical balance tool for fall risk assessments: A development and usability study

BACKGROUND

Falls are a significant source of early morbidity and mortality in the aging population, yet clinical changes that lead to increased fall risks often escape early identification and intervention. A device to measure postural control would facilitate evidence-based fall risk assessment.

OBJECTIVES

Our objectives were to iteratively develop a prototype quantitative posture instrument (QuPI) to replace the weight scale and to assess barriers and facilitators of its implementation in a clinical setting.

METHODS

We undertook an iterative formative evaluation and usability study of QuPI prototypes in primary care, medical oncology, sports medicine, cardiology, and endocrinology outpatient clinics. Clinicians evaluated an initial QuPI prototype and completed a semi-structured interview to determine critical functionality, inform design, and assess usability. The QuPI was then modified according to the results, and a new prototype was tested and evaluated.

RESULTS

Eighteen clinicians participated in both rounds of interviews. Clinicians who participated (referred to as participants) reported willingness to use the QuPI with all patients during the first round of interviews and stated they would replace their current weight scale with the modified QuPI during the second round of interviews. Participants identified design elements that were both facilitators and barriers to use. Usability scores for both prototypes were excellent. Despite several national guidelines for fall risk assessments, lack of consistent use of guidelines by care teams was found to be a barrier to effective fall risk assessments.

CONCLUSION

The QuPI provides a new method for quantifying fall risks with good user acceptance, usability, and clinical feasibility without disrupting workflow. The QuPI supplemented and facilitated the use of standard algorithms for fall risk assessment. Greater education of the entire care team regarding evidence-based fall risk assessment will promote adherence to guidelines and fall prevention.

Knowledge, attitude, and practice towards occupational burnout among doctors and nurses in intensive care unit

Background

Occupational burnout is prevalent among doctors and nurses. This study aimed to investigate the knowledge, attitude, and practice (KAP) of ICU doctors and nurses regarding occupational burnout.

Methods

A cross-sectional study was conducted between December 2023 and June 2024 at the Zhejiang Medical & Health Group Hangzhou Hospital in Zhejiang Province. Demographic information and KAP scores were collected through distributed questionnaires. Occupational burnout was measured by the Maslach Burnout Inventory-General Survey (MBI-GS).

Results

This study included 105 doctors and 165 nurses, with an average age of 32.23 ± 7.38 years. Among all the participants, 6 (2.22%) reported no occupational burnout, 230 (85.19%) experienced moderate occupational burnout, and 34 (12.59%) reported severe occupational burnout. The mean knowledge, attitude, and practice scores were 9.64 ± 4.21 (possible range: 0-18), 29.01 ± 3.15 (possible range: 7-35), and 16.96 ± 4.29 (possible range: 6-30), respectively. Multivariate logistic regression revealed that a higher knowledge score was independently associated with more proactive practice (OR = 1.33, 95% CI: [1.18, 1.50], p < 0.001). Structural equation modeling showed that knowledge positively influenced both (β = 0.33, p < 0.001) and practice (β = 0.37, p < 0.001), while practice negatively impacted the MBI-GS (β = -0.92, p < 0.001).

Conclusion

Most ICU doctors and nurses exhibited moderate occupational burnout, with insufficient knowledge, positive attitude, and moderate practice toward occupational burnout. Implementing strategies to increase knowledge and promote active practical engagement is essential to effectively mitigate occupational burnout among ICU staff.

Decision aid for surgical management of benign prostatic hyperplasia - Assessing acceptability of the French version

INTRODUCTION

Exploring all surgical interventions for benign prostatic hyperplasia (BPH) can be time-consuming. We developed the first online CUA-endorsed BPH surgical Patient Decision Aid (PtDA), including all guideline-approved surgical modalities. Our study assesses the acceptability of the tool's French version (FRv) among patients and urologists.

MATERIAL

A PtDA was developed including 9 surgical modalities: monopolar transurethral resection of the prostate (TURP), bipolar TURP, GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open retropubic prostatectomy, and robotic simple prostatectomy. Ten urologists who perform BPH surgery and 21 patients with a history of BPH surgery were recruited. Alpha-testing was performed for the FRv and compared to the English version (ENv).

RESULTS

In both versions of the PtDA, the language was considered clear (urologists FRv 78%; ENv 92%, patients FRv 91%; ENv 100%) and outcomes correctly reported (urologists FRv 71%; ENv 82%) and well explained (patients FRv 91%; ENv 90%). Most patients believed the PtDA would have been useful during their consultation (FRv=86%, ENv=89%), and all recommended it for future patients. A higher proportion of patients, versus urologists, found the PtDA of appropriate duration (urologists FRv 46%; ENv 64%, patients FRv 90%; ENv 84%) and length (urologists FRv 54%; ENv 64%, patients FRv 57%; ENv 84%). Urologists mainly recommended text lightening and integrating illustrations.

CONCLUSION

While the FRv was found to be acceptable, it underperformed the ENv among urologists due to its information overload. The FRv will be rendered more concise to facilitate its integration into clinical practice.

EVIDENCE GRADE

4.

Understanding Perceptions, Knowledge and Implementation Barriers of Enhanced Recovery After Surgery Among Surgeons and Anesthesiologists

Objective The present study aimed to evaluate the knowledge, perceptions, and barriers associated with Enhanced Recovery After Surgery (ERAS) implementation among perioperative clinicians. Methods This cross-sectional study included responses from 214 perioperative clinicians, comprising surgeons and anesthesiologists involved in abdominal surgeries, from tertiary care hospitals in Khyber-Pakhtunkhwa, Pakistan. A structured questionnaire collected data on participants' knowledge of ERAS protocols, perceived barriers to implementation, and learning preferences. Responses were analyzed using descriptive and inferential statistics, with significance set at p<0.05. Results This study included 214 perioperative clinicians, predominantly residents (91.6%, n=196), from surgery (90.2%, n=193) and anesthesiology (9.8%, n=21) departments. Knowledge about ERAS protocols was limited, with 89 (41.6%) of respondents stating they knew nothing and 97 (45.3%) reporting very little or some familiarity. Perceived barriers included lack of institutional support, time constraints, and insufficient research. Most participants, 145 (67.8%), supported integrating ERAS education into formal training, with 92 (42.9%) favoring seminars or lectures and 79 (36.9%) preferring journal articles for learning. Perceptions of ERAS importance were generally positive, but significant differences were noted regarding hospital administration support (p=0.013). Conclusion This study identifies significant gaps in ERAS knowledge among perioperative clinicians, particularly among residents, and highlights perceived logistical barriers to its implementation. However, the findings are limited by the underrepresentation of consultants and anesthesiologists, who are key drivers of ERAS programs. The findings highlight the need for targeted educational interventions, stronger institutional support, and multidisciplinary collaboration to improve ERAS adoption.

A reproducible framework for monitoring the impact of randomized clinical trials on clinical practice using large-scale real-world data: application to gynaecological surgical trials using the French national healthcare database

Background

Randomized clinical trials (RCTs) are fundamental to evidence-based medicine, but their real-world impact on clinical practice often remains unmonitored. Leveraging large-scale real-world data can enable systematic monitoring of RCT effects. We aimed to develop a reproducible framework using real-world data to assess how major RCTs influence medical practice, using two pivotal surgical RCTs in gynaecologic oncology as an example-the LACC (Laparoscopic Approach to Cervical Cancer) and LION (Lymphadenectomy in Ovarian Neoplasms) trials.

Methods

We utilized data from the French National Health Insurance Database (SNDS), covering 98.8% of France's population. We analysed patients who underwent radical hysterectomy for cervical cancer (2013-2022) and patients who underwent cytoreductive surgery for ovarian cancer (2014-2022). Bayesian structural time series analysis assessed the causal effects of the LACC and LION trials on the discontinuation of minimally invasive surgery (MIS) and lymphadenectomy, respectively. Analyses were stratified by hospital type, academic status, research mission, domain expertise, human resources, and financial condition.

Findings

Our nationwide cohorts included 7108 cervical cancer and 23,090 ovarian cancer patients treated across 596 centres. The LACC trial led to a 14.1% reduction in radical hysterectomies by MIS (275 fewer surgeries; 95% CI: -407 to -140), with academic centres showing 27.9% reduction compared to 2.5% increase in nonacademic centres. The LION trial resulted in a 22.6% reduction in lymphadenectomies (2358 fewer surgeries; 95% CI: -2708 to -2003), with academic centres achieving 31.1% reduction versus 15% in nonacademic centres. Significant variation was observed across medical settings. Centres with academic status, high research missions, substantial expertise, and robust resources were more responsive to trial outcomes, highlighting the influence of institutional and human factors on adopting new practices.

Interpretation

This study demonstrates that large-scale real-world data can effectively monitor the impact of RCTs on clinical practice. While validated here using surgical trials, this reproducible framework is adaptable to various health domains and can be implemented in any country with national electronic health databases. Systematic monitoring is essential to ensure effective implementation of RCT findings and to address disparities in the adoption of evidence-based practices.

Funding

None.

The Centre for Evidence-Based Orthopaedics Tool for the Implementation of Evidence-Based Practice

Introduction Updating practices can be challenging in evidence-based practice when integrating the evidence, clinical expertise, and patient values and preferences. Implementing evidence-based practice requires individual, collective, and organizational behavioral changes. Effective behavior change interventions are necessary to facilitate the implementation of new evidence. We propose a tool to facilitate the implementation of evidence in clinical decision-making by changing healthcare providers' behaviors. Methods The Centre for Evidence-Based Orthopaedics (CEBO) tool was developed to bridge the gap between evidence and practice in a hospital department. The development process follows a Plan-Do-Study-Act (PDSA) structure and is based on the COM-B model (Capability, Opportunity, Motivation, Behavior) and the Theoretical Domains Framework (TDF), which recognize that effective behavior change necessitates addressing factors at both individual and organizational levels. The CEBO tool consists of four phases, guiding the process from identifying an evidence-practice gap to evaluating behavioral changes following implementation. Results We applied the CEBO tool to two surgical cases, which led to substantial behavioral changes in orthopedic surgeons' treatment choices. Our findings indicate that the CEBO tool is feasible and can influence surgeons' behaviors to align more closely with the best available evidence. Conclusion The CEBO tool helps align practice with the best available evidence. Although implementing new practices effectively is time-consuming, it seems achievable with the CEBO tool. Substantial behavioral changes were observed among surgeons in both cases.

A multidisciplinary comprehensive nursing Management Approach for Catheter-related bloodstream infections

BACKGROUND

Catheter-related bloodstream infection (CR-BSI) stands as one of the leading causes of hospital-acquired infections, often resulting in high healthcare expenditure and mortality rates. Despite efforts, reducing the incidence of CR-BSI remains a significant challenge.

OBJECTIVE

This study aimed to assess the impact of a multidisciplinary organizational intervention on reducing intravenous CR-BSI.

METHODS

A quality improvement team was established to implement various interventions, utilizing the FOCUS-PDCA continuous quality improvement model and fishbone diagram for analysis and improvement.

RESULTS

After the interventions, operational indicators for catheter insertion, maintenance, and removal improved from 82.50% ± 1.15%, 83.60% ± 1.60%, and 81.60% ± 1.80-95.30% ± 1.00%, 96.20% ± 1.62%, and 97.25% ± 0.50%, respectively. Additionally, catheter dwell time decreased from 7.50 ± 0.85 days to 3.50 ± 0.75 days, and the quarterly infection rate was reduced from 2.328% ± 1.85-0.305% ± 0.95% following the implementation of the intervention.

DISCUSSION

Despite the available evidence, there remains a noticeable gap between the ideal evidence-based practices and their practical implementation. We aim to eradicate CR-BSIs within the surgical intensive care units (ICUs) of hospitals. To achieve this goal, we have introduced a comprehensive quality improvement framework designed not only to benefit our own ICU but also to serve as a model for implementation in other similar healthcare settings.

Assessing a Continuing Education Course for Dental Hygienists to Improve HPV and HPV Vaccine Knowledge and Self-efficacy

Human papillomavirus is the most common sexually transmitted infection and causes anogenital and oropharyngeal cancers. Although HPV-related cancers can be prevented through vaccination, HPV vaccination rates are low compared to other vaccines. One of the strongest indicators for vaccination is provider recommendation, and dental health providers are well positioned to promote HPV vaccination among their patients. The purpose of this study was to determine if a continuing education (CE) course could improve dental hygienists' HPV-related knowledge and self-efficacy related to HPV vaccination recommendations. Data were collected from a sample of participants (n = 202) at a large dental hygiene conference in the southern US. A pre- and post-tests were administered with the CE course and differences in HPV vaccine knowledge and self-efficacy in counseling, recommending, and referring for the HPV vaccine were analyzed using SAS. HPV vaccine knowledge overall significantly increased post-CE (p < .001) and improvement was seen among several specific knowledge areas. However, knowledge regarding the common sites of HPV-related oral and oropharyngeal cancers remained moderate (82% correct) even after the CE intervention. There was no significant change from pre-test to post-test in participants' self-efficacy related to counseling patients about the HPV vaccine, recommending the HPV vaccine to patients, or referring patients for the vaccine. This study demonstrates that continuing education can improve dental hygienists' HPV-related knowledge. Since dental providers may play an important role in HPV-related cancer prevention, future work should develop continuing education tools that can motivate changes in self-efficacy and ultimately improve practice behaviors.

Factors associated with willingness to perform expedited excisional treatment for patients at high risk for cervical precancer

Background

The 2019 ASCCP Risk-Based Management Consensus Guidelines prefer expedited treatment, defined as proceeding to excisional treatment without first performing colposcopic biopsy, for patients with screening results indicating a high risk of cervical precancer. In this mixed methods study, we explored clinician attitudes toward expedited treatment.

Methods

In 2021, a national sample of 671 clinicians who performed colposcopy completed surveys; a subset (n = 41) of clinicians who performed colposcopy and/or directed patient treatment completed qualitative interviews.

Results

Among 671 colposcopists, 25.7 % were currently performing expedited treatment, 50.8% were not currently using expedited treatment but were willing to adopt this change, and 23.6% were not willing to perform expedited treatment. Binomial regression analyses indicated that internal medicine and family medicine clinicians (compared to Obstetrician-Gynecologists), and those practicing in academic medal centers (compared to private practice) had higher odds of currently performing expedited treatment; internal and family medicine clinicians also reported higher odds of being willing to adopt this change. Qualitative interviews highlighted benefits including improved cancer prevention among older patients, reduced loss to follow-up, reduction of time and expense for patients, and allowing shared decision-making. Concerns expressed related to future pregnancy complications, lack of available excisional treatment services (e.g., LEEP), patient preference, avoiding over- and under-treatment, and using biopsy results to plan excisional procedures.

Conclusions

Approximately 25 % of colposcopists are currently performing expedited treatment, and an additional 50 % would be willing to adopt this practice for high-risk patients. Improving access to expedited treatment for appropriate patients could improve cervical cancer prevention.