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Simula AS, Malmivaara A, Booth N, Karppinen J. Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial. J Rehabil Med 2024; 56:jrm28321. [PMID: 38643363 PMCID: PMC11151494 DOI: 10.2340/jrm.v56.28321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/03/2024] [Indexed: 04/22/2024] Open
Abstract
OBJECTIVE The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care. DESIGN A benchmarking controlled trial design was used. SUBJECTS/PATIENTS Three primary healthcare areas and 654 low back pain patients with or without sciatica. METHODS Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months. RESULTS No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003). Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.
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Affiliation(s)
- Anna Sofia Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of General
Medicine, Wellbeing services county of South Savo (ELOISA), Mikkeli, Finland.
| | - Antti Malmivaara
- Finnish Institute for Health and Welfare, Helsinki, Finland; Orton Orthopaedic Hospital, Helsinki, Finland
| | - Neill Booth
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Mills K, Bowden JL, Boland R, Pardey M, Descallar J, Naylor JM. Taking the first step: protocol for a cluster randomised implementation trial comparing strategies on access to exercise programmes for people with knee osteoarthritis. BMJ Open 2023; 13:e071045. [PMID: 37567743 PMCID: PMC10423770 DOI: 10.1136/bmjopen-2022-071045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/29/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION This cluster randomised implementation trial will assess the effect of two behavioural change interventions on the proportion of people with structural knee osteoarthritis (OA) referred and attending exercise-based professionals (physiotherapists and exercise physiologists). The interventions are designed to increase awareness of guidelines, benefits and access pathways for exercise therapy. We hypothesise either strategy will result in more people with knee OA being referred and attending physiotherapy/exercise physiology than current standard of care. METHODS AND ANALYSIS We will recruit 30 radiology clinics. 10 clinics will be randomly assigned to each trial arm with 1020 people with knee OA consecutively recruited (102 people per practice) into each arm. Intervention arm 1 is an educational reminder message targeted at primary care practitioners with a hyperlink to national guidelines regarding knee OA clinical management. It will be included in the reporting template of a plain knee X-ray. Intervention arm 2 is the reminder message and a patient-facing infographic explaining the benefits and access pathways for exercise. Both interventions will be delivered once, by the radiology clinics, when a person undergoes plain X-ray for non-traumatic knee pain/dysfunction. The primary outcome is referral to physiotherapist/exercise physiology. The secondary outcome is attendance to that appointment. Both outcomes are self-reported via an online survey administered 4 weeks after the X-ray. Additional survey questions explore facilitators and barriers to appointment attendance and acceptability of the interventions. A subsample of the intervention groups will be recruited for semistructured telephone-based interviews to further explore these latter outcomes. ETHICS AND DISSEMINATION The study protocol was approved by Macquarie University Human Research Ethics Committee (#520221190343842) and prospectively registered with the Australian New Zealand Clinical Trials Registry. The findings of the trial will be disseminated through peer-reviewed scientific journals and conferences. We will engage with Australian physician colleges and main-stream media to distribute findings. TRIAL REGISTRATION NUMBER ACTRN12622001414707p.
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Affiliation(s)
- Kathryn Mills
- Department of Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jocelyn L Bowden
- Institute of Bone and Joint Research, The University of Sydney, St Leonards, New South Wales, Australia
| | - Robert Boland
- Discipline of Physiotherapy, The University of Sydney, Camperdown, New South Wales, Australia
| | - Margery Pardey
- Department of Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Joseph Descallar
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Justine M Naylor
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
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Farmer C, Bourne A, Haas R, Wallis J, O'Connor D, Buchbinder R. Can modifications to how medical imaging findings are reported improve quality of care? A systematic review. Clin Radiol 2022; 77:428-435. [DOI: 10.1016/j.crad.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/09/2022] [Indexed: 12/24/2022]
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Farmer C, O'Connor DA, Lee H, McCaffery K, Maher C, Newell D, Cashin A, Byfield D, Jarvik J, Buchbinder R. Consumer understanding of terms used in imaging reports requested for low back pain: a cross-sectional survey. BMJ Open 2021; 11:e049938. [PMID: 34518265 PMCID: PMC8438839 DOI: 10.1136/bmjopen-2021-049938] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To investigate (1) self-reported societal comprehension of common and usually non-serious terms found in lumbar spine imaging reports and (2) its relationship to perceived seriousness, likely persistence of low back pain (LBP), fear of movement, back beliefs and history and intensity of LBP. DESIGN Cross-sectional online survey of the general public. SETTING Five English-speaking countries: UK, USA, Canada, New Zealand and Australia. PARTICIPANTS Adults (age >18 years) with or without a history of LBP recruited in April 2019 with quotas for country, age and gender. PRIMARY AND SECONDARY OUTCOME MEASURES Self-reported understanding of 14 terms (annular fissure, disc bulge, disc degeneration, disc extrusion, disc height loss, disc protrusion, disc signal loss, facet joint degeneration, high intensity zone, mild canal stenosis, Modic changes, nerve root contact, spondylolisthesis and spondylosis) commonly found in lumbar spine imaging reports. For each term, we also elicited worry about its seriousness, and whether its presence would indicate pain persistence and prompt fear of movement. RESULTS From 774 responses, we included 677 (87.5%) with complete and valid responses. 577 (85%) participants had a current or past history of LBP of whom 251 (44%) had received lumbar spine imaging. Self-reported understanding of all terms was poor. At best, 235 (35%) reported understanding the term 'disc degeneration', while only 71 (10.5%) reported understanding the term 'Modic changes'. For all terms, a moderate to large proportion of participants (range 59%-71%), considered they indicated a serious back problem, that pain might persist (range 52%-71%) and they would be fearful of movement (range 42%-57%). CONCLUSION Common and usually non-serious terms in lumbar spine imaging reports are poorly understood by the general population and may contribute to the burden of LBP. TRIAL REGISTRATION NUMBER ACTRN12619000545167.
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Affiliation(s)
- Caitlin Farmer
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Denise A O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Hopin Lee
- Centre for Statistics in Medicine, Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher Maher
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | | | - Aidan Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - David Byfield
- University of South Wales Faculty of Life Sciences and Education, Treforest, UK
| | - Jeffrey Jarvik
- Departments of Radiology, Neurological Surgery and Health Services, School of Medicine, University of Washington, Seattle, Washington, USA
- UW Clinical Learning, Evidence And Research (CLEAR) Center for Musculoskeletal Disorders, University of Washington, Seattle, Washington, USA
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
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Gransjøen AM, Wiig S, Lysdahl KB, Hofmann BM. Health care personnel's perception of guideline implementation for musculoskeletal imaging: a process evaluation. BMC Health Serv Res 2020; 20:397. [PMID: 32393317 PMCID: PMC7212587 DOI: 10.1186/s12913-020-05272-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/29/2020] [Indexed: 01/29/2023] Open
Abstract
Background The increasing complexity and variability in radiology have significantly fueled the need for guidelines. There are many methods for disseminating and implementing guidelines however; and obtaining lasting changes has been difficult. Implementation outcome is usually measured in a decrease in unwarranted examinations, and qualitative data are rarely used. This study’s aim was to evaluate a guideline implementation process and identify factors influencing implementation outcome using qualitative data. Methods Seven general practitioners and five radiological personnel from a Norwegian county participated in four focus group interviews in 2019. The data were analyzed using qualitative content analysis, where some categories were predetermined, while most were drawn from the data. Results Four main categories were developed from the data material. 1) Successful/unsuccessful parts of the implementation, 2) perceived changes/lack of changes after the implementation, 3) environment-related factors that affected guideline use, and 4) User related factors that affect guideline use. Conclusions Our findings show that clinical guideline implementation is difficult, despite the implementation strategy being tailored to the target groups. Several environment- and user-related factors contributed to the lack of changes experienced in practice for both general practitioners and radiological personnel.
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Affiliation(s)
- Ann Mari Gransjøen
- Department of Health sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.
| | - Siri Wiig
- SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholmsgate 41, 4036, Stavanger, Norway
| | - Kristin Bakke Lysdahl
- Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, University of South-Eastern Norway, Box 235, 3603, Kongsberg, PO, Norway
| | - Bjørn Morten Hofmann
- Department of Health sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.,Center for medical ethics, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway
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Grimshaw JM, Ivers N, Linklater S, Foy R, Francis JJ, Gude WT, Hysong SJ. Reinvigorating stagnant science: implementation laboratories and a meta-laboratory to efficiently advance the science of audit and feedback. BMJ Qual Saf 2019; 28:416-423. [PMID: 30852557 PMCID: PMC6559780 DOI: 10.1136/bmjqs-2018-008355] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 01/08/2019] [Accepted: 02/12/2019] [Indexed: 11/04/2022]
Abstract
Audit and feedback (A&F) is a commonly used quality improvement (QI) approach. A Cochrane review indicates that A&F is generally effective and leads to modest improvements in professional practice but with considerable variation in the observed effects. While we have some understanding of factors that enhance the effects of A&F, further research needs to explore when A&F is most likely to be effective and how to optimise it. To do this, we need to move away from two-arm trials of A&F compared with control in favour of head-to-head trials of different ways of providing A&F. This paper describes implementation laboratories involving collaborations between healthcare organisations providing A&F at scale, and researchers, to embed head-to-head trials into routine QI programmes. This can improve effectiveness while producing generalisable knowledge about how to optimise A&F. We also describe an international meta-laboratory that aims to maximise cross-laboratory learning and facilitate coordination of A&F research.
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Affiliation(s)
- J M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada .,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Noah Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Department of Family Medicine and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jill J Francis
- Health Services Research and Management Division, City University of London, London, UK
| | - Wouter T Gude
- Department of Medical Informatics, Academic Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sylvia J Hysong
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
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Azman RR, Shah MNM, Ng KH. Radiation Safety in Emergency Medicine: Balancing the Benefits and Risks. Korean J Radiol 2019; 20:399-404. [PMID: 30799570 PMCID: PMC6389812 DOI: 10.3348/kjr.2018.0416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/09/2018] [Indexed: 01/01/2023] Open
Abstract
The use of computed tomography (CT) in emergency departments has increased over several decades, as physicians increasingly depend on imaging for diagnoses. Patients and medical personnel are put at risk due to frequent exposure to and higher levels of radiation, with very little evidence of improvements in outcomes. Here, we explore why CT imaging has a tendency to be overused in emergency departments and the obstacles that medical personnel face in ensuring patient safety. The solution requires cooperation from all emergency care stakeholders as well as the continuous education of doctors on how CT scans help in particular cases.
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Affiliation(s)
- Raja Rizal Azman
- Department of Biomedical Imaging, University Malaya Research Imaging Centre (UMRIC), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Mohammad Nazri Md Shah
- Department of Biomedical Imaging, University Malaya Research Imaging Centre (UMRIC), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kwan Hoong Ng
- Department of Biomedical Imaging, University Malaya Research Imaging Centre (UMRIC), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Gransjøen AM, Wiig S, Lysdahl KB, Hofmann BM. Development and conduction of an active re-implementation of the Norwegian musculoskeletal guidelines. BMC Res Notes 2018; 11:785. [PMID: 30390703 PMCID: PMC6215611 DOI: 10.1186/s13104-018-3894-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/27/2018] [Indexed: 11/10/2022] Open
Abstract
Objective Significant geographical variations in the use of diagnostic imaging have been demonstrated in Norway and elsewhere. Non-traumatic musculoskeletal conditions is one area where this has been demonstrated. A national musculoskeletal guideline was implemented in response by online publishing and postal dissemination in Norway in 2014 by national policy makers. The objective of our study was to develop and conduct an intervention as an active re-implementation of this guideline in one Norwegian county to investigate and facilitate guideline adherence. The development and implementation process is reported here, to facilitate understanding of the future evaluation results of this study. Results The consolidated framework for implementation research guided the intervention development and implementation. The implementation development was also based on earlier reported success factors in combination with interviews with general practitioners and radiologists regarding facilitators and barriers to guideline adherence. A combined implementation strategy was developed, including educational meetings, shortening of the guideline and easier access. All the aspects of the implementation strategy were adapted towards general practitioners, radiological personnel and the Norwegian Labor and Welfare Administration. Sixteen educational meetings were held, and six educational videos were made for those unable to attend, or where meetings could not be held. Electronic supplementary material The online version of this article (10.1186/s13104-018-3894-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ann Mari Gransjøen
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.
| | - Siri Wiig
- Faculty of Health Sciences, SHARE-Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholmsgate 41, 4036, Stavanger, Norway
| | - Kristin Bakke Lysdahl
- Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, University of South-Eastern Norway, PO Box 235, 3603, Kongsberg, Norway
| | - Bjørn Morten Hofmann
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.,Center for Medical Ethics, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway
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Bandong AN, Leaver A, Mackey M, Ingram R, Shearman S, Chan C, Cameron ID, Moloney N, Mitchell R, Doyle E, Leyten E, Rebbeck T. Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia. BMC Health Serv Res 2018; 18:622. [PMID: 30089495 PMCID: PMC6083615 DOI: 10.1186/s12913-018-3439-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.
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Affiliation(s)
- Aila Nica Bandong
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
- College of Allied Medical Professions, University of the Philippines, Manila, Philippines
- Musculoskeletal Lab/Refshauge Lab (S218), Faculty of Health Sciences, The University of Sydney – Cumberland Campus, 75 East Street, Lidcombe, NSW 2141 Australia
| | - Andrew Leaver
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Martin Mackey
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Rodney Ingram
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Samantha Shearman
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Christen Chan
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, Sydney, Australia
| | - Niamh Moloney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rebecca Mitchell
- Macquarie University, Australian Institute of Health Innovation, Sydney, Australia
| | - Eoin Doyle
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Emma Leyten
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Trudy Rebbeck
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
- John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, Sydney, Australia
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Radiation protection: Factors influencing compliance to referral guidelines in minor chest trauma. Eur Radiol 2017; 28:1420-1426. [DOI: 10.1007/s00330-017-5093-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/05/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
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Mesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskelet Disord 2016; 17:258. [PMID: 27286812 PMCID: PMC4902903 DOI: 10.1186/s12891-016-1110-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/01/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recommendations in clinical practice guidelines for non-specific low back pain (NSLBP) are not necessarily translated into practice. Multiple studies have investigated different interventions to implement best evidence into clinical practice yet no synthesis of these studies has been carried out to date. The aim of this study was to systematically review available studies to determine whether implementation interventions in this field have been effective and to identify which strategies have been most successful in changing healthcare practitioner behaviours and improving patient outcomes. METHODS A systematic review was undertaken, searching electronic databases until end of December 2012 plus hand searching, writing to key authors and using prior knowledge of the field to identify papers. Included studies evaluated an implementation intervention to improve the management of NSLBP in clinical practice, measured key outcomes regarding change in practitioner behaviour and/or patient outcomes and subjected their data to statistical analysis. The Cochrane Effective Practice and Organisation of Care (EPOC) recommendations about systematic review conduct were followed. Study inclusion, data extraction and study risk of bias assessments were conducted independently by two review authors. RESULTS Of 7654 potentially eligible citations, 17 papers reporting on 14 studies were included. Risk of bias of included studies was highly variable with 7 of 17 papers rated at high risk. Single intervention or one-off implementation efforts were consistently ineffective in changing clinical practice. Increasing the frequency and duration of implementation interventions led to greater success with those continuously ongoing over time the most successful in improving clinical practice in line with best evidence recommendations. CONCLUSIONS Single intervention or one-off implementation interventions may seem attractive but are largely unsuccessful in effecting meaningful change in clinical practice for NSLBP. Increasing frequency and duration of implementation interventions seems to lead to greater success and the most successful implementation interventions used consistently sustained strategies.
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Affiliation(s)
| | - Nadine E Foster
- NIHR Musculoskeletal Health in Primary Care, Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, England, ST5 5BG
| | - Simon David French
- Canadian Chiropractic Research Foundation Professorship in Rehabilitation Therapy, School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada; Senior Research Fellow, Centre for Health, Exercise and Sports Medicine, School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
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Francis L, Dunt D, Cadilhac DA. How is the sustainability of chronic disease health programmes empirically measured in hospital and related healthcare services?-a scoping review. BMJ Open 2016; 6:e010944. [PMID: 27246000 PMCID: PMC4893855 DOI: 10.1136/bmjopen-2015-010944] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Programmes to address chronic disease are a focus of governments worldwide. Despite growth in 'implementation science', there is a paucity of knowledge regarding the best means to measure sustainability. The aim of this review was to summarise current practice for measuring sustainability outcomes of chronic disease health programmes, providing guidance for programme planners and future directions for the academic field. SETTINGS A scoping review of the literature spanning 1985-2015 was conducted using MEDLINE, CINAHL, PsychINFO and The Cochrane Library limited to English language and adults. Main search terms included chronic disease, acute care, sustainability, institutionalisation and health planning. A descriptive synthesis was required. Settings included primary care, hospitals, mental health centres and community health. PARTICIPANTS Programmes included preventing or managing chronic conditions including diabetes, heart disease, depression, respiratory disease, cancer, obesity, dental hygiene and multiple chronic diseases. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome measures included clarifying a sustainability definition, types of methodologies used, timelines for assessment, criteria levels to determine outcomes and how methodology varies between intervention types. RESULTS Among 153 abstracts retrieved, 87 were retained for full article review and 42 included in the qualitative synthesis. Five definitions for sustainability outcome were identified with 'maintenance of programme activities' most frequent. Achieving sustainability was dependent on inter-relationships between various organisational and social contexts supporting a broad scale approach to evaluation. An increasing trend in use of mixed methods designs over multiple time points to determine sustainability outcomes was found. CONCLUSIONS Despite the importance and investment in chronic disease programmes, few studies are undertaken to measure sustainability. Methods to evaluate sustainability are diverse with some emerging patterns in measurement found. Use of mixed methods approaches over multiple time points may serve to better guide measurement of sustainability. Consensus on aspects of standardised measurement would promote the future possibility of meta-analytic syntheses.
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Affiliation(s)
- Linda Francis
- The University of Melbourne, Melbourne School of Population and Global Health, Centre for Health Policy, Melbourne Health Centre for Excellence in Neuroscience, Ballarat, Victoria, Australia
| | - David Dunt
- Centre for Health Policy, The University of Melbourne, Melbourne School of Population and Global Health, Parkville, Victoria, Australia
| | - Dominique A Cadilhac
- Translational Public Health Unit, Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Head Public Health: Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia
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Tzortziou Brown V, Underwood M, Mohamed N, Westwood O, Morrissey D. Professional interventions for general practitioners on the management of musculoskeletal conditions. Cochrane Database Syst Rev 2016; 2016:CD007495. [PMID: 27150167 PMCID: PMC10523188 DOI: 10.1002/14651858.cd007495.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs. OBJECTIVES To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013. SELECTION CRITERIA We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions. MAIN RESULTS Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low. AUTHORS' CONCLUSIONS There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.
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Affiliation(s)
- Victoria Tzortziou Brown
- Blizard Institute, Barts and The London School of Medicine and Dentistry.Centre for Primary Care and Public HealthLondonUK
- Barts and The London School of Medicine and Dentistry, Queen Mary University of LondonCentre for Sports and Exercise Medicine, William Harvey Research Institute,LondonUKE1 4DG
| | - Martin Underwood
- Warwick Medical SchoolWarwick Clinical Trials UnitCoventryWarwickshireUKCV4 7AL
| | | | - Olwyn Westwood
- Warwick Medical School, The University of WarwickGibbet Hall CampusCoventryUKCV4 7AL
| | - Dylan Morrissey
- Queen Mary University of LondonSport and Exercise MedicineLondonUK
- Barts Health NHS TrustPhysiotherapy DepartmentLondonUK
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Where to build the bridge between evidence and practice?: results of an international workshop to prioritize knowledge translation activities in traumatic brain injury care. J Head Trauma Rehabil 2015; 29:268-76. [PMID: 24984091 DOI: 10.1097/htr.0000000000000053] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Treatment of patients with traumatic brain injury (TBI) should be based upon the strongest evidence to achieve optimal patient outcomes. Given the challenges, efforts involved, and delays in uptake of evidence into practice, priorities for knowledge translation (KT) should be chosen carefully. An international workshop was convened to identify KT priorities for acute and rehabilitation care of TBI and develop KT projects addressing these priorities. METHODS An expert panel of 25 neurotrauma clinicians, researchers, and KT scientists representing 4 countries examined 66 neurotrauma research topics synthesized from 2 neurotrauma evidence resources: Evidence Based Review of Acquired Brain Injury and Global Evidence Mapping projects. The 2-day workshop combined KT theory presentations with small group activities to prioritize topics using a modified Delphi method. RESULTS Four acute care topics and 3 topics in the field of rehabilitation were identified. These were focused into 3 KT project proposals: optimization of intracranial pressure and nutrition in the first week following TBI; cognitive rehabilitation following TBI; and vocational rehabilitation following TBI. CONCLUSION Three high-priority KT projects were developed: the first combined 2 important topics in acute TBI management of intracranial pressure management and nutrition, and the other projects focused on cognitive rehabilitation and vocational rehabilitation.
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 2014; 64:e765-74. [PMID: 25452541 PMCID: PMC4240149 DOI: 10.3399/bjgp14x682837] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/11/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING Systematic review. METHOD Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield
| | | | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield
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Remedios D, Hierath M, Ashford N, Bezzi M, Cavanagh P, Chateil JF, Grenier P, Simeonov G, Vilgrain V. Imaging referral guidelines in Europe: now and in the future-EC Referral Guidelines Workshop Proceedings. Insights Imaging 2013; 5:9-13. [PMID: 24338616 PMCID: PMC3948903 DOI: 10.1007/s13244-013-0299-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 11/07/2013] [Indexed: 11/30/2022] Open
Abstract
As an integral part of the European Commission (EC) Imaging Referral Guidelines Project a 1.5-day workshop was held in Vienna on 20–21 September, 2012. At this workshop, models and good practices regarding the appropriateness and use of imaging referral guidelines (Guidelines) in Europe and worldwide were presented, together with the results of a survey of Guidelines in Europe. The latter included ideas, innovations and wishes for future Community action. Recommendations for future Community action:Stronger measures should be taken by the EC and the European competent authorities for making Guidelines available and used in all EU member states. Evidence-based Guidelines with separate guidance for children should be issued or endorsed by a trusted European organisation. Educational initiatives and electronic requesting in connection with clinical decision support (CDS) systems should be used to improve the implementation of Guidelines. Monitoring of Guidelines implementation and use should be by clinical audit, particularly external audit, but also by local/internal audit.
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A practitioner's guide to developing critical appraisal skills: translating research into clinical practice. J Am Dent Assoc 2012; 143:386-90. [PMID: 22467699 DOI: 10.14219/jada.archive.2012.0181] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OVERVIEW To understand research and develop skills in adopting research findings, clinicians must overcome a series of challenges. First is determining exactly what constitutes evidence-based care. The amount of often contradictory research findings and "expert" opinion that is available can be overwhelming and should not always be taken as best evidence. Accessing the best evidence has its own set of difficulties. Then there is the final challenge of actually incorporating that best evidence into practice, as knowing what should be done rarely is enough to bring about an immediate change in what is done. However, there are means available to help overcome these barriers. CONCLUSIONS AND PRACTICE IMPLICATIONS Critical summaries of systematic reviews, along with evidence-based treatment recommendations, have emerged as highly condensed, easily accessible vehicles for staying current with research findings. There also is emerging evidence of effective strategies for implementing research findings in practice, as well as organizations with which clinicians can engage to ensure that their patient care is based on the best scientific information available.
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Krist AH, Woolf SH, Rothemich SF, Johnson RE, Peele JE, Cunningham TD, Longo DR, Bello GA, Matzke GR. Interactive preventive health record to enhance delivery of recommended care: a randomized trial. Ann Fam Med 2012; 10:312-9. [PMID: 22778119 PMCID: PMC3392290 DOI: 10.1370/afm.1383] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Americans receive only one-half of recommended preventive services. Information technologies have been advocated to engage patients. We tested the effectiveness of an interactive preventive health record (IPHR) that links patients to their clinician's record, explains information in lay language, displays tailored recommendations and educational resources, and generates reminders. METHODS This randomized controlled trial involved 8 primary care practices. Four thousand five hundred patients were randomly selected to receive a mailed invitation to use the IPHR or usual care. Outcomes were measured using patient surveys and electronic medical record data and included IPHR use and service delivery. Comparisons were made between invited and usual-care patients and between users and nonusers among those invited to use the IPHR. RESULTS At 4 and 16 months, 229 (10.2%) and 378 (16.8%) of invited patients used the IPHR. The proportion of patients up-to-date with all services increased between baseline and 16 months by 3.8% among intervention patients (from 11.4% to 15.2%, P <.001) and by 1.5% among control patients (from 11.1% to 12.6%, P = .07), a difference of 2.3% (P = .05). Greater increases were observed among patients who used the IPHR. At 16 months, 25.1% of users were up-to-date with all services, double the rate among nonusers. At 4 months, delivery of colorectal, breast, and cervical cancer screening increased by 19%, 15%, and 13%, respectively, among users. CONCLUSIONS Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits.
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Affiliation(s)
- Alex H Krist
- Department of Family Medicine, Virginia Commonwealth University, Richmond, VA 23298-0251, USA.
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Malone J, Guleria R, Craven C, Horton P, Järvinen H, Mayo J, O'reilly G, Picano E, Remedios D, Le Heron J, Rehani M, Holmberg O, Czarwinski R. Justification of diagnostic medical exposures: some practical issues. Report of an International Atomic Energy Agency Consultation. Br J Radiol 2012; 85:523-38. [PMID: 21343316 PMCID: PMC3479887 DOI: 10.1259/bjr/42893576] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 05/29/2010] [Accepted: 06/03/2010] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES The Radiation Protection of Patients Unit of the International Atomic Energy Agency (IAEA) is concerned about the effectiveness of justification of diagnostic medical exposures. Recent published work and the report of an initial IAEA consultation in the area gave grounds for such concerns. There is a significant level of inappropriate usage, and, in some cases, a poor level of awareness of dose and risk among some key groups involved. This article aims to address this. METHODS The IAEA convened a second group of experts in November 2008 to review practical and achievable actions that might lead to more effective justification. RESULTS This report summarises the matters that this group considered and the outcome of their deliberations. There is a need for improved communication, both within professions and between professionals on one hand, and between professionals and the patients/public on the other. Coupled with this, the issue of consent to imaging procedures was revisited. The need for good evidence-based referral guidelines or criteria of acceptability was emphasised, as was the need for their global adaptation and dissemination. CONCLUSION Clinical audit was regarded as a key tool in ensuring that justification becomes an effective, transparent and accountable part of normal radiological practice. In summary, justification would be facilitated by the "3 As": awareness, appropriateness and audit.
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Affiliation(s)
- J Malone
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, NSRW, International Atomic Energy Agency, Vienna, Austria.
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Remedios D. Justification: how to get referring physicians involved. RADIATION PROTECTION DOSIMETRY 2011; 147:47-51. [PMID: 21729936 DOI: 10.1093/rpd/ncr263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Barriers to involvement of clinicians in the process of justification include an already overloaded knowledge base, lack of time, inconsistent guidance and disproportionate patient expectations. Strategies to improve referring physicians' input include education, use of imaging referral guidelines, clinical audit and regulation. This article discusses and reviews evidence for approaches to encourage greater participation in justification by clinicians. Approaches are best summarised by 'Awareness, appropriateness and audit'.
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French SD, Green S, Buchbinder R, Barnes H. Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions. Cochrane Database Syst Rev 2010; 2010:CD006094. [PMID: 20091583 PMCID: PMC7390432 DOI: 10.1002/14651858.cd006094.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Imaging is commonly performed for musculoskeletal conditions. Identifying interventions to improve the appropriate use of imaging for musculoskeletal conditions could potentially result in improved health outcomes for patients and reduced health care costs. OBJECTIVES To determine the effects of interventions that aim to improve the appropriate use of imaging for people with musculoskeletal conditions. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (June 2007), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (January 1966 to June 2007), EMBASE (January 1980 to June 2007) and CINAHL (January 1982 to June 2007). We also searched reference lists of included studies and relevant reviews. We undertook citation searches of all included studies, contacted authors of included studies, and contacted other experts in the field of effective professional practice. SELECTION CRITERIA Randomised controlled trials, non-randomised controlled clinical trials and interrupted time-series analyses that evaluated interventions designed to improve the use of imaging for musculoskeletal symptoms. DATA COLLECTION AND ANALYSIS Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. MAIN RESULTS Twenty eight studies met our inclusion criteria. The majority of the studies were for the management of osteoporosis or low back pain, and most evaluated interventions aimed at health professionals. To improve the use of imaging in the management of osteoporosis, the effect of any type of intervention compared to no-intervention controls was modest (absolute improvement in bone mineral density test ordering +10%, IQR 0.0 to +27.7). Patient mediated, reminder, and organisational interventions appeared to have most potential for improving imaging use in osteoporosis. For low back pain studies, the most common intervention evaluated was distribution of educational materials and this showed varying effects. Other interventions in low back pain studies also showed variable effects. For other musculoskeletal conditions, distribution of educational materials, educational meetings and audit and feedback were not shown to be effective for changing imaging ordering behaviour. Across all conditions, increasing the number of intervention components did not increase effect. AUTHORS' CONCLUSIONS For improving the use of imaging in osteoporosis, most professional interventions demonstrated benefit, and patient mediated, reminder, and organisational interventions appeared to have most potential for benefit. For low back pain studies interventions showed varying effects. For other musculoskeletal conditions, no firm conclusions can be drawn.
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Affiliation(s)
- Simon D French
- Monash UniversityMonash Institute of Health Services Research43 ‐ 51 Kanooka GroveMonash Medical Centre, Locked Bag 29ClaytonVICAustralia3168
| | - Sally Green
- Monash UniversityMonash Institute of Health Services Research43 ‐ 51 Kanooka GroveMonash Medical Centre, Locked Bag 29ClaytonVICAustralia3168
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology at Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Hayley Barnes
- Monash Institute of Health Services Researchc/o Australasian Cochrane CentreLocked Bag 29Monash Medical CentreClaytonVictoriaAustralia3168
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Bywood PT, Lunnay B, Roche AM. Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback. Drug Alcohol Rev 2008; 27:548-58. [PMID: 18696301 DOI: 10.1080/09595230802245535] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.
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Affiliation(s)
- Petra T Bywood
- National Centre for Education and Training on Addiction, Flinders University, South Australia, Australia.
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Ní Shúilleabháin A, O'Kelly M, O'Kelly F, O'Dowd T. Limited options: a report on GP access to services. Ir J Med Sci 2007; 176:27-32. [PMID: 17849520 DOI: 10.1007/s11845-007-0006-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Structure of Irish General Practice over 23 years was the third in a series of national studies that examined the development of general practice in 1982, 1992, and 2005. AIMS This study analysed specific data from the 2005 survey to determine the types of services offered by GPs, and to examine the changes in access to diagnostic/treatment services from 1982 to 2005. METHODS A questionnaire was sent to a stratified random sample of Irish GPs seeking information on their practice. RESULTS 476 (87%) valid questionnaires were returned. The range of services offered by GPs had increased. Access to diagnostic/treatment services was limited, and varied considerably depending on the type of practice. Access to chest X-rays and skeletal X-rays had decreased. CONCLUSIONS Access to existing services must be increased, and significant resources must be put into the development of dedicated primary care services.
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Affiliation(s)
- A Ní Shúilleabháin
- Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, AMNCH, Tallaght, Dublin 24, Ireland.
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Foy R, Hawthorne G, Gibb I, Eccles MP, Steen N, Hrisos S, White T, Croal BL, Grimshaw JM. A cluster randomised controlled trial of educational prompts in diabetes care: study protocol. Implement Sci 2007; 2:22. [PMID: 17650309 PMCID: PMC1973073 DOI: 10.1186/1748-5908-2-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 07/24/2007] [Indexed: 11/11/2022] Open
Abstract
Background Laboratory services have a central role in supporting screening, diagnosis, and management of patients. The increase in chronic disease management in primary care for conditions such as diabetes mellitus requires regular monitoring of patients' biochemical parameters. This process offers a route for improving the quality of care that patients receive by using test results as a vehicle for delivering educational messages as well as the test result itself. Aim To develop and evaluate the effectiveness of a quality improvement initiative to improve the care of patients with diabetes using test report reminders. Design A programme of four cluster randomised controlled trials within one population of general practices. Participants General practices in Newcastle-upon-Tyne, UK. Intervention Brief educational messages added to paper and electronic general practice laboratory test reports introduced over two phases. Phase One messages, attached to Haemoglobin A1c (HbA1c) reports, targeted glycaemic and cholesterol control. Phase Two messages, attached to albumin:creatinine ratio (ACR) reports, targeted blood pressure (BP) control and foot inspection. Outcomes General practice mean levels of HbA1c and cholesterol (Phase One) and diastolic and systolic BP and proportions of patients having undergone foot inspections (Phase Two); number of tests requested. Trial registration Current Controlled Trial ISRCTN2186314.
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Affiliation(s)
- Robbie Foy
- Institute for Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
| | - Gillian Hawthorne
- Newcastle Primary Care Trust, Benfield Road, Newcastle Upon Tyne, NE6 4PF, UK
| | - Ian Gibb
- Newcastle Hospitals NHS Trust, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK
| | - Martin P Eccles
- Institute for Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
| | - Nick Steen
- Institute for Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
| | - Susan Hrisos
- Institute for Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
| | - Trevor White
- Newcastle Primary Care Trust, Benfield Road, Newcastle Upon Tyne, NE6 4PF, UK
| | - Bernard L Croal
- Grampian University Hospitals Trust, Foresterhill, Aberdeen, AB25 2ZN, UK
| | - Jeremy M Grimshaw
- Ottawa Health Research Institute, 725 Parkdale Avenue, Ottawa, ON K1Y 4E9, Canada
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Peat G, Thomas E, Duncan R, Wood L, Wilkie R, Hill J, Hay EM, Croft P. Estimating the probability of radiographic osteoarthritis in the older patient with knee pain. ACTA ACUST UNITED AC 2007; 57:794-802. [PMID: 17530679 DOI: 10.1002/art.22785] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine whether clinical information can practically rule in or rule out the presence of radiographic osteoarthritis in older adults with knee pain. METHODS We conducted a cross-sectional diagnostic study involving 695 adults ages >/=50 years reporting knee pain within the last year identified by postal survey and attending a research clinic. Potential indicators of radiographic osteoarthritis were gathered by self-complete questionnaires, clinical interview, and physical examination. Participants underwent plain radiography (posteroanterior, skyline, and lateral views). Radiographic osteoarthritis was defined as the presence of definite osteophytes in at least 1 joint compartment of the index knee. RESULTS Independent predictors of radiographic osteoarthritis were age, sex, body mass index, absence of whole leg pain, traumatic onset, difficulty descending stairs, palpable effusion, fixed-flexion deformity, restricted-flexion range of motion, and crepitus. Using this model, 245 participants had a predicted probability >/=80% (practical rule in), of whom 231 (94%) actually had radiographic osteoarthritis (specificity 93%). Twenty-one participants had a predicted probability <20% (practical rule out), of whom only 2 (10%) had radiographic osteoarthritis (sensitivity 99.6%). The predicted probability of radiographic osteoarthritis for the remaining 429 participants fell into an intermediate category (20-79%). CONCLUSION Simple clinical information can be used to estimate the probability of radiographic osteoarthritis in individual patients. However, for the majority of community-dwelling older adults with knee pain this method enables the presence of radiographic osteoarthritis to be neither confidently ruled in nor ruled out. Prospective validation and updating of these findings in an independent sample is required.
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Mandryk JA, Mackson JM, Horn FE, Wutzke SE, Badcock CA, Hyndman RJ, Weekes LM. Measuring change in prescription drug utilization in Australia. Pharmacoepidemiol Drug Saf 2006; 15:477-84. [PMID: 16700084 DOI: 10.1002/pds.1247] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PURPOSE The National Prescribing Service Ltd (NPS) aims to improve prescribing and use of medicines consistent with evidence-based best practice. This report compares two statistical methods used to determine whether multiple educational interventions influenced antibiotic prescription in Australia. METHODS Monthly data (July 1996 to June 2003) were obtained from a national claims database. The outcome measures were the median number of antibiotic prescriptions per 1000 consultations for each general practitioner (GP) each month, and the mean proportion (across GPs) of each subgroup of antibiotics (e.g. roxithromycin) out of nine antibiotics having primary use for upper respiratory tract infection. Two approaches were used to investigate shifts in prescribing: augmented regression, which included seasonality, autocorrelation and one intervention; and seasonally adjusted piecewise linear dynamic regression, which removed seasonality prior to modelling, included several interventions, GP participation and autocorrelated errors. Both methods are variations of piecewise linear regression modelling. RESULTS Both approaches described a similar decrease in rates, with a non-significant change after the first intervention. The inclusion of more interventions and GP participation made no difference. Using roxithromycin as an example of the analyses of proportions, both approaches implied that after the first intervention the proportion decreased significantly. The statistical significance of this intervention disappears when other interventions are included. CONCLUSIONS The two analyses provide results which agree regarding the possible impact of the NPS interventions, but raise questions about what is the best way to model drug utilization, particularly regarding whether to include all intervention terms when they belong to an extended roll-out of related interventions.
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Affiliation(s)
- John A Mandryk
- National Prescribing Service Ltd, Surry Hills, Sydney, NSW, Australia.
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