Interventions to increase the use of electronic health information by healthcare practitioners to improve clinical practice and patient outcomes

Emergency department use of an electronic differential diagnosis generator in the evaluation of critically ill patients

BACKGROUND

Accurate diagnosis is an essential component of managing critically ill emergency department (ED) patients. Electronic diagnosis generators (EDGs) are software tools which assist clinicians in their diagnosis generation; however, they have not been evaluated for use for critical ED patients. We aimed to evaluate the use of an EDG for this population to determine its impact on diagnosis generation and diagnostic testing.

METHODS

We performed an observational study on usage of an EDG in the high-acuity area of a tertiary care ED. The EDG was used by residents evaluating each patient in the area. The resident used the EDG when the case was felt to have diagnostic uncertainty and completed a data collection tool. Data were summarized by frequencies. Chi-squared or Fisher's exact tests were used to assess the association of added value of the EDG for diagnosis generation and diagnostic testing.

RESULTS

Over the 8-month study period, the EDG was utilized to evaluate 98 critical ED patients, of whom 60% were female, 7% were pediatric, and 46% were elderly. It was used most commonly for gastroenterological, infectious disease/immunologic, metabolic/renal, and neuropsychiatric presentations, and was least used for trauma presentations. Use of the EDG led to a diagnosis not initially considered in 47% of cases and led to additional diagnostic testing in 4% of cases.

CONCLUSION

EDGs have some potential to improve diagnosis in critical EM patients by expanding the differential diagnosis and, to a lesser extent, altering diagnostic testing.

The practical ethics of repurposing health data: how to acknowledge invisible data work and the need for prioritization

Throughout the Global North, policymakers invest in large-scale integration of health-data infrastructures to facilitate the reuse of clinical data for administration, research, and innovation. Debates about the ethical implications of data repurposing have focused extensively on issues of patient autonomy and privacy. We suggest that it is time to scrutinize also how the everyday work of healthcare staff is affected by political ambitions of data reuse for an increasing number of purposes, and how different purposes are prioritized. Our analysis builds on ethnographic studies within the Danish healthcare system, which is internationally known for its high degree of digitalization and well-connected data infrastructures. Although data repurposing ought to be relatively seamless in this context, we demonstrate how it involves costs and trade-offs for those who produce and use health data. Even when IT systems and automation strategies are introduced to enhance efficiency and reduce data work, they can end up generating new forms of data work and fragmentation of clinically relevant information. We identify five types of data work related to the production, completion, validation, sorting, and recontextualization of health data. Each of these requires medical expertise and clinical resources. We propose that the implications for these forms of data work should be considered early in the planning stages of initiatives for large-scale data sharing and reuse, such as the European Health Data Space. We believe that political awareness of clinical costs and trade-offs related to such data work can provide better and more informed decisions about data repurposing.

Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women’s alcohol consumption during pregnancy

Background

There are significant challenges in ensuring sufficient clinician participation in quality improvement training. Clinician capability has been identified as a barrier to the delivery of evidence-based care. Clinician training is an effective strategy to address this barrier, however, there are significant challenges in ensuring adequate clinician participation in training. This study aimed to assess the extent of participation by antenatal clinicians in evidence-based training to address alcohol consumption during pregnancy, and to assess differences in participation by profession.

Methods

A 7-month training initiative based on six evidence-based principles was implemented in a maternity service in New South Wales, Australia. Descriptive statistics described participation in training (% attending: any training; six evidence-based principles of training; all principles). Regression analyses examined differences by profession.

Results

Almost all antenatal clinicians participated in some training (182/186; 98%); 69% participated in ≥1 h of training (μ = 88.2mins, SD:56.56). The proportion of clinicians participating in training that satisfied each of the six principles ranged from 35% (training from peers and experts) to 82% (training was educational and instructional). Only 7% participated in training that satisfied all principles. A significantly higher proportion of midwifery compared to medical clinicians participated in training satisfying five of the six training principles.

Conclusions

A training initiative based on evidence-based principles resulted in almost all clinicians receiving some training and 69% participating in at least 1 h of training. Variability between professions suggests training needs to be tailored to such groups. Further research is required to determine possible associations with care delivery outcomes.

Trial registration

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Development and palliative care staff reactions to a sleep regulation educational intervention

Background

In palliative care, sleep and circadian rhythm problems are common symptoms. Nonpharmacological interventions are available; however, health care providers are not aware of these or lack the knowledge to effectively implement in practice. This study reports the content and design development of the PRIME™ (Program for Improving & Managing Environments for Sleep) sleep online educational intervention as well as the evaluation of the intervention by practicing nurses with a focus on perceived acceptability and satisfaction.

Methods

Development of the education employed a multi-step process that assesses the current state of the science in this area (literature reviews), the needs of regional target recipients (hospice/palliative care staff), expert recommendations and views of a national pool of hospice/palliative workers. A cross-sectional, descriptive study with key staff informants evaluated the acceptability and usability of the modules using both scale-response items to rate the content and design of the modules and overall satisfaction and five open-response questions to suggest changes to the educational intervention.

Results

Among 31 palliative care professionals, most rated the content and design favorably. A total of 20 participants provided suggestions to improve the educational intervention. Their comments were categorized into six themes: Integration into Practice; Content, Exercises and Material Provided by Modules; User Interface and Design; and Adapt and Expand Modules for Public, Family and Caregivers.

Conclusions

The data suggest that the PRIME™ educational intervention can be an effective tool to train direct-care palliative care professionals on interventions for use in their daily practice. We also demonstrated that the educational intervention is feasible to deliver online and that the online modules appealed to respondents, suggesting that future delivery of the educational intervention can use the same or similar modes of presentation.

What are the effects of teaching Evidence-Based Health Care (EBHC) at different levels of health professions education? An updated overview of systematic reviews

BACKGROUND

Evidence-based healthcare (EBHC) knowledge and skills are recognised as core competencies of healthcare professionals worldwide, and teaching EBHC has been widely recommended as an integral part of their training. The objective of this overview of systematic reviews (SR) was to update evidence and assess the effects of various approaches for teaching evidence-based health care (EBHC) at undergraduate (UG) and postgraduate (PG) medical education (ME) level on changes in knowledge, skills, attitudes and behaviour.

METHODS AND FINDINGS

This is an update of an overview that was published in 2014. The process followed standard procedures specified for the previous version of the overview, with a modified search. Searches were conducted in Epistemonikos for SRs published from 1 January 2013 to 27 October 2020 with no language restrictions. We checked additional sources for ongoing and unpublished SRs. Eligibility criteria included: SRs which evaluated educational interventions for teaching EBHC compared to no intervention or a different strategy were eligible. Two reviewers independently selected SRs, extracted data and evaluated quality using standardised instrument (AMSTAR2). The effects of strategies to teach EBHC were synthesized using a narrative approach. Previously published version of this overview included 16 SR, while the updated search identified six additional SRs. We therefore included a total of 22 SRs (with a total of 141 primary studies) in this updated overview. The SRs evaluated different educational interventions of varying duration, frequency, and format to teach various components of EBHC at different levels of ME (UG, PG, mixed). Most SRs assessed a range of EBHC related outcomes using a variety of assessment tools. Two SRs included randomised controlled trials (RCTs) only, while 20 reviews included RCTs and various types of non-RCTs. Diversity of study designs and teaching activities as well as aggregated findings at the SR level prevented comparisons of the effects of different techniques. In general, knowledge was improved across all ME levels for interventions compared to no intervention or pre-test scores. Skills improved in UGs, but less so in PGs and were less consistent in mixed populations. There were positive changes in behaviour among UGs and PGs, but not in mixed populations, with no consistent improvement in attitudes in any of the studied groups. One SR showed improved patient outcomes (based on non-randomised studies). Main limitations included: poor quality and reporting of SRs, heterogeneity of interventions and outcome measures, and short-term follow up.

CONCLUSIONS

Teaching EBHC consistently improved EBHC knowledge and skills at all levels of ME and behaviour in UGs and PGs, but with no consistent improvement in attitudes towards EBHC, and little evidence of the long term influence on processes of care and patient outcomes. EBHC teaching and learning should be interactive, multifaceted, integrated into clinical practice, and should include assessments.

STUDY REGISTRATION

The protocol for the original overview was developed and approved by Stellenbosch University Research Ethics Committee S12/10/262.

UPDATE OF THE OVERVIEW

Young T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLoS One. 2014;9(1):e86706. doi: 10.1371/journal.pone.0086706.

Pre-return to work consultation and therapeutic part-time work: Cross-sectional study on level of knowledge and use by general practitioners in France

BACKGROUND

In France, general practitioners (GPs) may use two tools specifically designed to help employees who experience difficulties in returning to work after sick leave: the pre-return-to-work (PRW) medical consultation and therapeutic part-time (TPT) work.

OBJECTIVES

The objective was to investigate the level of knowledge and use of these two tools by GPs in Maine-et-Loire, France.

METHODS

This cross-sectional study was performed using a telephone questionnaire to evaluate the level of knowledge of GPs and the use of these two tools in patients having difficulties returning to work.

RESULTS

Among the 200 randomly selected GPs, 122 responded (response rate: 61%). More than half of the interviewed GPs declared they 'often' (46%) or 'always' (14%) contacted the occupational physician in these situations. Moreover, 62.2% and 32.7% believed that they had a 'vague' or 'very good' level of knowledge, and 41% and 51% declared either 'frequent' or 'regular' level of use of the PRW medical consultation, respectively. Regarding TPT work, 47% and 53% reported a 'very good' or 'vague' level of knowledge, and 41% and 51% a 'frequent' or 'regular' level of use, respectively. GPs who had a better level of knowledge of this tool reported a higher level of use (p < 0.001).

CONCLUSION

This study shows that while the level of knowledge and use of the PRW medical consultation and TPT work is good, it is not optimal. This could be improved by organising training courses for GPs. Obstacles to their wider use could be investigated further in a qualitative study.

Improving nurses' readiness for evidence-based practice in critical care units: results of an information literacy training program

BACKGROUND

One of the most important prerequisites for nurses' readiness to implement Evidence-Based Practice (EBP) is to improve their information literacy skills. This study aimed to evaluate the impact of a training program on nurses' information literacy skills for EBP in critical care units.

METHODS

In this interventional study, 60 nurses working in critical care units of hospitals affiliated to Kerman University of Medical Sciences were randomly assigned into the intervention or control groups. The intervention group was provided with information literacy training in three eight-hour sessions over 3 weeks. Data were collected using demographic and information literacy skills for EBP questionnaires before and 1 month after the intervention.

RESULTS

At baseline, the intervention and control groups were similar in terms of demographic characteristics and information literacy skills for EBP. The training program significantly improved all dimensions of information literacy skills of the nurses in the intervention group, including the use of different information resources (3.43 ± 0.48, p < 0.001), information searching skills and the use of different search features (3.85 ± 0.67, p < 0.001), knowledge about search operators (3.74 ± 0.14, p < 0.001), and selection of more appropriate search statement (x2 = 50.63, p = 0.001) compared with the control group.

CONCLUSIONS

Nurses can learn EBP skills and apply research findings in their nursing practice in order to provide high-quality, safe nursing care in clinical settings. Practical workshops and regular training courses are effective interventional strategies to equip nurses with information literacy skills so that they can apply these skills to their future nursing practice.

Assessing the effect of virtual education on information literacy competency for evidence-based practice among the undergraduate nursing students

Background

Information literacy competency is one of the requirements to implement Evidence-Based Practice (EBP) in nursing. It is necessary to pay attention to curricular development and use new educational methods such as virtual education to strengthen information literacy competency in nursing students. Given the scarcity of the studies on the effectiveness of virtual education in nursing, particularly in Iran, and the positive university atmosphere regarding the use of virtual education, this study investigated the effect of virtual education on the undergraduate nursing students’ information literacy competency for EBP.

Methods

This interventional study was performed with two groups of intervention and control and a pretest and posttest design. Seventy-nine nursing students were selected and assigned to the intervention or control groups by random sampling. Virtual education of the information literacy was uploaded on a website in the form of six modules delivered in four weeks. Questionnaires of demographic information and information literacy for EBP were used to collect data before and one month after the virtual education.

Results

The results showed no significant difference between the control and intervention groups in all dimensions of information literacy competency in the pre-test stage. In the post-test, the virtual education improved dimensions of information seeking skills (t = 3.14, p = 0.002) and knowledge about search operators (t = 39.84, p = 0.001) in the intervention groups compared with the control group. The virtual education did not have any significant effect on the use of different information resources and development of search strategy with assessing the frequency of selecting the most appropriate search statement in the intervention group.

Conclusion

Virtual education had a significant effect on information seeking skills and knowledge about search operators in nursing students. Nurse educators can benefit from our experiences in designing this method for the use of virtual education programs in nursing schools. Given the lack of effectiveness of this program in using different information resources and development of search strategy, nurse educators are recommended to train information literacy for EBP by integrating several approaches such as virtual (online and offline) and face-to-face education.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Translating Clinical Questions by Physicians Into Searchable Queries: Analytical Survey Study

BACKGROUND

Staying up to date and answering clinical questions with current best evidence from health research is challenging. Evidence-based clinical texts, databases, and tools can help, but clinicians first need to translate their clinical questions into searchable queries. MacPLUS FS (McMaster Premium LiteratUre Service Federated Search) is an online search engine that allows clinicians to explore multiple resources simultaneously and retrieves one single output that includes the following: (1) evidence from summaries (eg, UpToDate and DynaMed), (2) preappraised research (eg, EvidenceAlerts), and (3) non-preappraised research (eg, PubMed), with and without validated bibliographic search filters. MacPLUS FS can also be used as a laboratory to explore clinical questions and evidence retrieval.

OBJECTIVE

Our primary objective was to examine how clinicians formulate their queries on a federated search engine, according to the population, intervention, comparison, and outcome (PICO) framework. Our secondary objective was to assess which resources were accessed by clinicians to answer their questions.

METHODS

We performed an analytical survey among 908 clinicians who used MacPLUS FS in the context of a randomized controlled trial on search retrieval. Recording account log-ins and usage, we extracted all 1085 queries performed during a 6-month period and classified each search term according to the PICO framework. We further categorized queries into background (eg, "What is porphyria?") and foreground questions (eg, "Does treatment A work better than B?"). We then analyzed the type of resources that clinicians accessed.

RESULTS

There were 695 structured queries, after exclusion of meaningless queries and iterations of similar searches. We classified 56.5% (393/695) of these queries as background questions and 43.5% (302/695) as foreground questions, the majority of which were related to questions about therapy (213/695, 30.6%), followed by diagnosis (48/695, 6.9%), etiology (24/695, 3.5%), and prognosis (17/695, 2.5%). This distribution did not significantly differ between postgraduate residents and medical faculty physicians (P=.51). Queries included a median of 3 search terms (IQR 2-4), most often related to the population and intervention or test, rarely related to the outcome, and never related to the comparator. About half of the resources accessed (314/610, 51.5%) were summaries, 24.4% (149/610) were preappraised research, and 24.1% were (147/610) non-preappraised research.

CONCLUSIONS

Our results, from a large sample of real-life queries, could guide the development of educational interventions to improve clinicians' retrieval skills, as well as inform the design of more useful evidence-based resources for clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02038439; https://www.clinicaltrials.gov/ct2/show/NCT02038439.

Digitalization and Physician Learning: Individual Practice, Organizational Context, and Social Norm

INTRODUCTION

The emerging context of online platforms and digitally engaged patients demands new competencies of health care professionals. Although information and communication technologies (ICTs) can strengthen continuous professional development (CPD) and learning at work, more research is needed on ICT for experiential and collegial learning.

METHODS

The study builds on prior qualitative research to identify issues and comprises a quantitative assessment of ICT usage for learning in health care. A survey was administered to Swedish physicians participating in a CPD program as part of specialist medical training. Conclusions focused specifically on learning dimensions are drawn from correlation analyses complemented with multiple regression.

RESULTS

The findings show that physicians' actual use of ICT is related to perceived performance, social influence, and organizational context. Social norm was the most important variable for measured general usage, whereas performance expectancy (perceived usefulness of ICT) was important for ICT usage for learning. The degree of individual digitalization affects performance and, in turn, actual use.

DISCUSSION

The study highlights the need to incorporate ICT effectively into CPD and clinical work. Besides formal training and support for specific systems, there is a need to understand the usefulness of digitalization integrated into practice. Moving beyond instrumentalist views of technology, the model in this study includes contextualized dimensions of ICT and learning in health care. Findings confirm that medical communities are influencers of use, which suggests that an emphasis on collegial expectations for digital collaboration will enhance practitioner adaptation.

Learning, understanding and the use of information technology: a survey study among primary care physician trainees

BACKGROUND

User understanding of information technology systems (IT-Systems) is a prerequisite for their use. This study aimed to explore how primary care physician trainees learn, understand and use IT-Systems.

METHODS

A paper-based survey study among 301 primary care physician trainees in Baden-Wuerttemberg, Germany, was performed. The questionnaire included measures of understanding and use of nine specific system features, five possible learning strategies, a validated scale for affinity for technology interaction, and five individual and three practice characteristics.

RESULTS

The sample comprised 94 respondents (31.6% response rate). Between 3.2 and 59.6% said to know specific systems features well; between 13.8 and 42.6% expressed a wish to know more about specific system features. The predominant strategy for learning system features was explanation by others: 51.7 to 66.7% had applied this strategy to learn the features. Between 18.6 and 41.4% had learned the features by trial and error. A better understanding of system features was associated with the use of a trial and error strategy for learning system features (beta = 0.260, p = 0.012). The use of a greater variety of learning strategies was associated with higher affinity for technology interaction (beta = 0.215, p = 0.037).

CONCLUSION

The study suggests that many physicians need a better understanding of IT-Systems. The role of manuals, online resources and courses in learning IT-Systems seems limited. The new generation of primary care physicians seem to learn features of IT-Systems through explanation by others and trying in their ambulatory practices. The relevance of IT-Systems in healthcare is high, but physicians need more support in learning to use system features.

Effect of a clinical evidence technology on patient skin disease outcomes in primary care: a cluster-randomized controlled trial

Objective

Providers' use of clinical evidence technologies (CETs) improves their diagnosis and treatment decisions. Despite these benefits, few studies have evaluated the impact of CETs on patient outcomes. The investigators evaluated the effect of one CET, VisualDx, on skin problem outcomes in primary care.

Methods

A cluster-randomized controlled pragmatic trial was conducted in outpatient clinics at an academic medical center in the northeastern United States. Participants were primary care providers (PCPs) and their adult patients seen for skin problems. The intervention was VisualDx, as used by PCPs. Outcomes were patient-reported time from index clinic visit to problem resolution, and the number of follow-up visits to any provider for the same problem. PCPs who were randomly assigned to the intervention agreed to use VisualDx as their primary evidence source for skin problems. Control group PCPs agreed not to use VisualDx. Investigators collected outcome data from patients by phone at thirty-day intervals. Cox proportional hazards models assessed time to resolution. Wilcoxon-rank sum tests and logistic regression compared the need for return appointments.

Results

Thirty-two PCPs and 433 patients participated. In proportional hazards modelling adjusted for provider clusters, the time from index visit to skin problem resolution was similar in both groups (hazard ratio=0.92; 95% confidence interval [CI]=0.70, 1.21; p=0.54). Patient follow-up appointments did not differ significantly between groups (odds ratio=1.26; CI=0.94, 1.70; p=0.29).

Conclusion

This pragmatic trial tested the effectiveness of VisualDx on patient-reported skin disease outcomes in a generalizable clinical setting. There was no difference in skin problem resolution or number of follow-up visits when PCPs used VisualDx.

Supporting Students With Electronic Health Record-Embedded Learning Aids: A Mixed-Methods Study

BACKGROUND

Students often perceive workplace-based learning as disconnected from what they learn in medical school. Interventions that deal with this issue regularly involve feedback and/or learning aids. Feedback has frequently been encouraged in previous research, whereas the use of aids is less understood.

OBJECTIVE

This study aims to investigate the added value of learning aids in making the connection and enhancing the transfer of learning between medical school and workplace-based learning.

METHODS

First-year students in postgraduate general practice training participated in a mixed-methods study. Within a quasi-experimental design, two conditions were investigated: (1) students having access to electronic health record (EHR)-embedded learning aids and feedback and (2) students only receiving feedback. Semistructured interviews were conducted and analyzed according to the thematic analysis approach.

RESULTS

Forty-four students participated in this study. No significant difference was found between the two conditions (t₄₂=-0.511, P=.61, 95% CI -4.86 to 2.90). Nevertheless, students used the aids frequently and found them useful. Given that the aids were familiar to students and contained practice-based instructions in an easily accessible format, they were perceived as feasible to use during workplace-based learning. They also appeared to stimulate transfer of learning, self-confidence, reflection, and interaction between student and supervisor.

CONCLUSIONS

Access to EHR-embedded learning aids offers additional support during, but also before and after, patient encounters. The aids can be easily implemented into workplace-based learning.

Clinical indicators for common paediatric conditions: Processes, provenance and products of the CareTrack Kids study

BACKGROUND

In order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities.

METHODS

Clinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care.

RESULTS

From 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit).

CONCLUSION

A set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review

Background

Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation.

Methods

A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation.

Results

Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions.

Conclusions

Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.

Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus

OBJECTIVE

To develop recommendations for the assessment of people with systemic lupus erythematosus (SLE) in Canada.

METHODS

Recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. The Canadian SLE Working Group (panel of Canadian rheumatologists and a patient representative from Canadian Arthritis Patient Alliance) was created. Questions for recommendation development were identified based on the results of a previous survey of SLE practice patterns of members of the Canadian Rheumatology Association. Systematic literature reviews of randomized trials and observational studies were conducted. Evidence to Decision tables were prepared and presented to the panel at 2 face-to-face meetings and online.

RESULTS

There are 15 recommendations for assessing and monitoring SLE, with varying applicability to adult and pediatric patients. Three recommendations focus on diagnosis, disease activity, and damage assessment, suggesting the use of a validated disease activity score per visit and annual damage score. Strong recommendations were made for cardiovascular risk assessment and measuring anti-Ro and anti-La antibodies in the peripartum period and conditional recommendations for osteoporosis and osteonecrosis. Two conditional recommendations were made for peripartum assessments, 1 for cervical cancer screening and 2 for hepatitis B and C screening. A strong recommendation was made for annual influenza vaccination.

CONCLUSION

These are considered the first guidelines using the GRADE method for the monitoring of SLE. Existing evidence is largely of low to moderate quality, resulting in more conditional than strong recommendations. Additional rigorous studies and special attention to pediatric SLE populations and patient preferences are needed.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

OBJECTIVES

Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

SETTING

Primary care.

PARTICIPANTS

Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

INTERVENTIONS

We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

RESULTS

All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

CONCLUSIONS

A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants

Objective

To understand clinicians' beliefs about practice variation and how variation might be reduced.

Methods

We surveyed board-certified physicians (N = 178), nurse practitioners (N = 60), and physician assistants (N = 12) at an academic medical center and two community clinics, representing family medicine, general internal medicine, and cardiology, from February—April 2016. The Internet-based questionnaire ascertained clinicians' beliefs regarding practice variation, clinical practice guidelines, and costs.

Results

Respondents agreed that practice variation should be reduced (mean [SD] 4.5 [1.1]; 1 = strongly disagree, 6 = strongly agree), but agreed less strongly (4.1 [1.0]) that it can realistically be reduced. They moderately agreed that variation is justified by situational differences (3.9 [1.2]). They strongly agreed (5.2 [0.8]) that clinicians should help reduce healthcare costs, but agreed less strongly (4.4 [1.1]) that reducing practice variation would reduce costs. Nearly all respondents (234/249 [94%]) currently depend on practice guidelines. Clinicians rated differences in clinician style and experience as most influencing practice variation, and inaccessibility of guidelines as least influential. Time to apply standards, and patient decision aids, were rated most likely to help standardize practice. Nurse practitioners and physicians assistants (vs physicians) and less experienced (vs senior) clinicians rated more favorably several factors that might help to standardize practice. Differences by specialty and academic vs community practice were small.

Conclusions

Clinicians believe that practice variation should be reduced, but are less certain that this can be achieved. Accessibility of guidelines is not a significant barrier to practice standardization, whereas more time to apply standards is viewed as potentially helpful.

Is There Evidence of Cost Benefits of Electronic Medical Records, Standards, or Interoperability in Hospital Information Systems? Overview of Systematic Reviews

BACKGROUND

Electronic health (eHealth) interventions may improve the quality of care by providing timely, accessible information about one patient or an entire population. Electronic patient care information forms the nucleus of computerized health information systems. However, interoperability among systems depends on the adoption of information standards. Additionally, investing in technology systems requires cost-effectiveness studies to ensure the sustainability of processes for stakeholders.

OBJECTIVE

The objective of this study was to assess cost-effectiveness of the use of electronically available inpatient data systems, health information exchange, or standards to support interoperability among systems.

METHODS

An overview of systematic reviews was conducted, assessing the MEDLINE, Cochrane Library, LILACS, and IEEE Library databases to identify relevant studies published through February 2016. The search was supplemented by citations from the selected papers. The primary outcome sought the cost-effectiveness, and the secondary outcome was the impact on quality of care. Independent reviewers selected studies, and disagreement was resolved by consensus. The quality of the included studies was evaluated using a measurement tool to assess systematic reviews (AMSTAR).

RESULTS

The primary search identified 286 papers, and two papers were manually included. A total of 211 were systematic reviews. From the 20 studies that were selected after screening the title and abstract, 14 were deemed ineligible, and six met the inclusion criteria. The interventions did not show a measurable effect on cost-effectiveness. Despite the limited number of studies, the heterogeneity of electronic systems reported, and the types of intervention in hospital routines, it was possible to identify some preliminary benefits in quality of care. Hospital information systems, along with information sharing, had the potential to improve clinical practice by reducing staff errors or incidents, improving automated harm detection, monitoring infections more effectively, and enhancing the continuity of care during physician handoffs.

CONCLUSIONS

This review identified some benefits in the quality of care but did not provide evidence that the implementation of eHealth interventions had a measurable impact on cost-effectiveness in hospital settings. However, further evidence is needed to infer the impact of standards adoption or interoperability in cost benefits of health care; this in turn requires further research.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 7: supporting staff in evidence-based decision-making, implementation and evaluation in a local healthcare setting

BACKGROUND

This is the seventh in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for resource allocation within a large Australian health service. It aimed to facilitate proactive use of evidence from research and local data; evidence-based decision-making for resource allocation including disinvestment; and development, implementation and evaluation of disinvestment projects. From the literature and responses of local stakeholders it was clear that provision of expertise and education, training and support of health service staff would be required to achieve these aims. Four support services were proposed. This paper is a detailed case report of the development, implementation and evaluation of a Data Service, Capacity Building Service and Project Support Service. An Evidence Service is reported separately.

METHODS

Literature reviews, surveys, interviews, consultation and workshops were used to capture and process the relevant information. Existing theoretical frameworks were adapted for evaluation and explication of processes and outcomes.

RESULTS

Surveys and interviews identified current practice in use of evidence in decision-making, implementation and evaluation; staff needs for evidence-based practice; nature, type and availability of local health service data; and preferred formats for education and training. The Capacity Building and Project Support Services were successful in achieving short term objectives; but long term outcomes were not evaluated due to reduced funding. The Data Service was not implemented at all. Factors influencing the processes and outcomes are discussed.

CONCLUSION

Health service staff need access to education, training, expertise and support to enable evidence-based decision-making and to implement and evaluate the changes arising from those decisions. Three support services were proposed based on research evidence and local findings. Local factors, some unanticipated and some unavoidable, were the main barriers to successful implementation. All three proposed support services hold promise as facilitators of EBP in the local healthcare setting. The findings from this study will inform further exploration.

Rising utilization of inpatient pediatric asthma pathways

INTRODUCTION

Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally.

OBJECTIVES

(1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways.

METHODS

We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables).

RESULTS

Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05).

CONCLUSIONS

From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.

Cardiovascular care guideline implementation in community health centers in Oregon: a mixed-methods analysis of real-world barriers and challenges

BACKGROUND

Spreading effective, guideline-based cardioprotective care quality improvement strategies between healthcare settings could yield great benefits, particularly in under-resourced contexts. Understanding the diverse factors facilitating or impeding such guideline implementation could improve cardiovascular care quality and outcomes for vulnerable patients.

METHODS

We sought to identify multi-level factors affecting uptake of cardioprotective care guidelines in community health centers (CHCs), within a successful trial of cross-setting implementation of an effective intervention. Quantitative analyses used multivariable logistic regression to examine in-person patient encounters at 10 CHCs from June 2011-May 2014. At these encounters, a point-of-care alert flagged adults with diabetes who were clinically indicated for, but not currently prescribed, cardioprotective medications. The main outcome measure was the rate of relevant prescriptions issued within two days of encounters. Qualitative analyses focused on CHC providers and staff, and, guided by the constant comparative method, were used to enhance understanding of the factors that influenced this prescribing.

RESULTS

Recommended prescribing occurred at 13-16% of encounters with patients who were indicated for such prescribing. The odds of this prescribing were higher when the patient was male, had HbA1c ≥7, was previously prescribed a similar medication, gave diabetes as the chief complaint, saw a mid-level practitioner, or saw their primary care provider. The odds were lower when the patient was insured, had ≥1 clinic visits in the past year, had kidney disease, or was prescribed certain other medications. Additional factors were associated with prescribing of each medication class. Qualitative results both supported and challenged the quantitative findings, illustrating important tensions involved in guideline-based prescribing. Clinic staff stressed the importance of the provider-patient relationship in guiding prescribing decisions in the face of competing priorities and care needs, and the impact of rapidly changing guidelines.

CONCLUSIONS

Diverse factors associated with guideline-concordant prescribing illuminate the complexity of delivering evidence-based care in CHCs. We present possible strategies for addressing barriers to guideline-based prescribing.

CLINICAL TRIALS REGISTRATION

This trial was registered retrospectively. Currently Controlled Trials NCT02299791 . Retrospectively registered 10 November 2014.

Improving rural and remote practitioners' knowledge of the diabetic foot: findings from an educational intervention

BACKGROUND

This study aimed to determine knowledge of national guidelines for diabetic foot assessment and risk stratification by rural and remote healthcare professionals in Western Australia and their implementation in practice. Assessment of diabetic foot knowledge, availability of equipment and delivery of foot care education in a primary healthcare setting at baseline enabled evaluation of the effectiveness of a diabetic foot education and training program for generalist healthcare professionals.

METHODS

This study employed a quasi-experimental pre-test/post-test study design. Healthcare practitioners' knowledge, attitudes and practice of diabetic foot assessment, diabetic foot risks, risk stratification, and use of the 2011 National Health and Medical Research Council Guidelines were investigated with an electronic pre-test survey(.) Healthcare professionals then undertook a 3-h education and training workshop before completing the electronic post-test knowledge, attitudes and practice survey. Comparison of pre-test/post-test survey findings was used to assess the change in knowledge, attitudes and intended practice due to the workshops.

RESULTS

Two hundred and forty-six healthcare professionals from two rural and remote health regions of Western Australia participated in training workshops. Monofilaments and diabetes foot care education brochures, particularly brochures for Aboriginal people, were reported as not readily available in rural and remote health services. For most participants (58 %), their post-test knowledge score increased significantly from the pre-test score. Use of the Guidelines in clinical settings was low (19 %). The healthcare professionals' baseline diabetic foot knowledge was adequate to correctly identify the high risk category. However, stratification of the intermediate risk category was poor, even after training.

CONCLUSION

This study reports the first assessment of Western Australia's rural and remote health professionals' knowledge, attitudes and practices regarding the diabetic foot. It shows that without training, generalists' levels of knowledge concerning the diabetic foot was low and they were unlikely to assess foot risk. The findings from this study in a rural and remote setting cast doubt on the ability of generalist healthcare professionals to stratify risk appropriately, especially for those at intermediate risk, without clinical decision support tools.

Specialist Bibliographic Databases

Specialist bibliographic databases offer essential online tools for researchers and authors who work on specific subjects and perform comprehensive and systematic syntheses of evidence. This article presents examples of the established specialist databases, which may be of interest to those engaged in multidisciplinary science communication. Access to most specialist databases is through subscription schemes and membership in professional associations. Several aggregators of information and database vendors, such as EBSCOhost and ProQuest, facilitate advanced searches supported by specialist keyword thesauri. Searches of items through specialist databases are complementary to those through multidisciplinary research platforms, such as PubMed, Web of Science, and Google Scholar. Familiarizing with the functional characteristics of biomedical and nonbiomedical bibliographic search tools is mandatory for researchers, authors, editors, and publishers. The database users are offered updates of the indexed journal lists, abstracts, author profiles, and links to other metadata. Editors and publishers may find particularly useful source selection criteria and apply for coverage of their peer-reviewed journals and grey literature sources. These criteria are aimed at accepting relevant sources with established editorial policies and quality controls.

Achieving universal testing for malaria

Rapid diagnostic tests have the potential to reduce the overtreatment of malaria by 95%, but time and extensive logistical, behavioural, and technical interventions may be required to achieve this, argue Eleanor Ochodo and colleagues