Implementation and trial evidence: a plea for fore-thought

Digital smartphone intervention to recognise and manage early warning signs in schizophrenia to prevent relapse: the EMPOWER feasibility cluster RCT

BACKGROUND

Relapse is a major determinant of outcome for people with a diagnosis of schizophrenia. Early warning signs frequently precede relapse. A recent Cochrane Review found low-quality evidence to suggest a positive effect of early warning signs interventions on hospitalisation and relapse.

OBJECTIVE

How feasible is a study to investigate the clinical effectiveness and cost-effectiveness of a digital intervention to recognise and promptly manage early warning signs of relapse in schizophrenia with the aim of preventing relapse?

DESIGN

A multicentre, two-arm, parallel-group cluster randomised controlled trial involving eight community mental health services, with 12-month follow-up.

SETTINGS

Glasgow, UK, and Melbourne, Australia.

PARTICIPANTS

Service users were aged > 16 years and had a schizophrenia spectrum disorder with evidence of a relapse within the previous 2 years. Carers were eligible for inclusion if they were nominated by an eligible service user.

INTERVENTIONS

The Early signs Monitoring to Prevent relapse in psychosis and prOmote Wellbeing, Engagement, and Recovery (EMPOWER) intervention was designed to enable participants to monitor changes in their well-being daily using a mobile phone, blended with peer support. Clinical triage of changes in well-being that were suggestive of early signs of relapse was enabled through an algorithm that triggered a check-in prompt that informed a relapse prevention pathway, if warranted.

MAIN OUTCOME MEASURES

The main outcomes were feasibility of the trial and feasibility, acceptability and usability of the intervention, as well as safety and performance. Candidate co-primary outcomes were relapse and fear of relapse.

RESULTS

We recruited 86 service users, of whom 73 were randomised (42 to EMPOWER and 31 to treatment as usual). Primary outcome data were collected for 84% of participants at 12 months. Feasibility data for people using the smartphone application (app) suggested that the app was easy to use and had a positive impact on motivations and intentions in relation to mental health. Actual app usage was high, with 91% of users who completed the baseline period meeting our a priori criterion of acceptable engagement (> 33%). The median time to discontinuation of > 33% app usage was 32 weeks (95% confidence interval 14 weeks to ∞). There were 8 out of 33 (24%) relapses in the EMPOWER arm and 13 out of 28 (46%) in the treatment-as-usual arm. Fewer participants in the EMPOWER arm had a relapse (relative risk 0.50, 95% confidence interval 0.26 to 0.98), and time to first relapse (hazard ratio 0.32, 95% confidence interval 0.14 to 0.74) was longer in the EMPOWER arm than in the treatment-as-usual group. At 12 months, EMPOWER participants were less fearful of having a relapse than those in the treatment-as-usual arm (mean difference -4.29, 95% confidence interval -7.29 to -1.28). EMPOWER was more costly and more effective, resulting in an incremental cost-effectiveness ratio of £3041. This incremental cost-effectiveness ratio would be considered cost-effective when using the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained.

LIMITATIONS

This was a feasibility study and the outcomes detected cannot be taken as evidence of efficacy or effectiveness.

CONCLUSIONS

A trial of digital technology to monitor early warning signs that blended with peer support and clinical triage to detect and prevent relapse is feasible.

FUTURE WORK

A main trial with a sample size of 500 (assuming 90% power and 20% dropout) would detect a clinically meaningful reduction in relapse (relative risk 0.7) and improvement in other variables (effect sizes 0.3-0.4).

TRIAL REGISTRATION

This trial is registered as ISRCTN99559262.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 27. See the NIHR Journals Library website for further project information. Funding in Australia was provided by the National Health and Medical Research Council (APP1095879).

A scoping literature review on minimum intervention dentistry for children with dental caries

Background Dental caries in children's permanent teeth remains a global burden. In contrast to the traditional approach of treating the disease through surgical operative intervention, minimum intervention has increasingly been recommended for managing children with dental caries.Aim This scoping review aimed to describe the literature related to the provision of minimum intervention dentistry for children with caries and to identify research gaps.Methods Electronic databases (Medline via Ovid, PubMed, Web of Science and Scopus) were searched, together with grey literature databases, and key organisation websites. Data was extracted on a piloted extraction template and a thematic analysis was undertaken.Results Sixty-seven relevant articles were identified. No empirical literature was identified that assessed a complete minimum intervention care pathway to managing caries. Five themes were identified from the scoping literature: evidence base, clinician attitude and skills, practice implementation, acceptability and environmental factors.Conclusions The majority of articles were opinion papers. There is a paucity of empirical evidence supporting the clinical and cost-effectiveness of a minimum intervention pathway for children with dental caries in primary dental care. The scoping review has identified some potential barriers to the implementation of such a care pathway, including regulatory and remunerative frameworks and clinical training/education.

Tradução do Conhecimento e os desafios contemporâneos na área da saúde: uma revisão de escopo

RESUMO A implementação das melhores evidências científicas nos serviços de saúde ainda não ocorre de forma satisfatória. Diante dessa problemática, o objetivo deste estudo foi investigar os desafios da Tradução do Conhecimento (TC) na área da saúde na atualidade. A metodologia desta revisão foi desenvolvida de acordo com os propósitos da revisão de escopo. Para tanto, as palavras-chave ‘translational medical research’ e ‘knowledge translation’ foram consultadas nos bancos de dados de periódicos da PubMed, Scopus e Web of Science. Foram incluídos os estudos publicados a partir do ano de 2008 até abril de 2018. Entre os 1.677 estudos encontrados, 839 artigos eram duplicados, e 818 não atendiam plenamente ao objetivo desta revisão; assim, 20 estudos foram submetidos à apreciação desse escopo. De acordo com as análises dos estudos, o desafio da TC advém de dois fatores: por um lado, a falta de coesão entre a comunidade científica e os tomadores de decisão em saúde; por outro, a inabilidade dos profissionais em traduzir e aplicar novos conhecimentos, além da omissão de apoio e de incentivos das instituições de saúde. Outrossim, esta revisão aborda um corpo significativo de diversos outros aspectos que limitam e/ou dificultam a TC área da saúde.

Handover from operating theatre to the intensive care unit: A quality improvement study

BACKGROUND

Transitioning a patient from the operating theatre (OT) to the intensive care unit (ICU) is a dynamic and complex process. Handover of the critically ill postoperative patient can contribute to procedural and communication errors. Standardised protocols are means for structuring and improving handover content. Both have been shown to be effective in reducing information omission and improve communication during this transition period.

OBJECTIVES

The aim of this uncontrolled before and after study was to improve handover processes and communication about the care for critically ill patients transferred from OT to ICU.

METHODS

Thirty-two OT to ICU handovers (16 before and 16 after implementation) were observed. Using a structured tool, we documented who was present, participated in, and initiated handover during ICU admission. Where and when handover was performed, information provided, distractions and interruptions, and handover duration were also recorded. Unstructured field notes and diagrams provided information on staff interaction. Following implementation, semistructured interviews with 27 participants were conducted to understand participants' perceptions of intervention acceptability and to determine factors influencing intervention implementation and spread.

FINDINGS

Following implementation, a "hands-off" approach was observed with fewer technical tasks completed during handover (43.8% before implementation vs 12.5% after implementation) without an increase in handover time. A single, multidisciplinary handover most often led by the anaesthetist was observed after implementation. Despite these improvements, the use of the physical checklist was not observed in practice, and an situation, background, assessment, recommendation (SBAR) format was not followed. Anaesthetists leading the handover did not view the handover checklist as being beneficial to their practice although some nurses were observed to use the checklist as a prompt for additional information.

CONCLUSIONS

A single, multidisciplinary handover demonstrated improvement in handover practice despite low uptake of the protocol checklist. Further information is required to inform targeted strategies to improve uptake and sustainability although broader interdisciplinary engagement and commitment may be helpful.

The knowledge mobilisation challenge: does producing evidence lead to its adoption within dentistry?

The transfer of evidence into clinical practice is the ultimate aim of those engaged in health research. But is this a process that occurs naturally? Can health researchers take it for granted that the evidence they produce will be embraced by clinicians and incorporated into their everyday practice? In this article, we use the example of oral healthcare in dependent older people and the issue of antibiotic prescribing by GDPs to illustrate the fact that successful knowledge transfer between researchers and practitioners cannot be automatically assumed. What is needed, so we argue, are certain tools to facilitate the knowledge transfer, exchange and implementation process. These tools may take the form of human intermediaries, who can occupy the space in between the worlds of research and practice, acting as brokers to mobilise knowledge, or through the establishment of communities of practice. We outline both of these approaches here as a potential solution to the problem of knowledge mobilisation in dentistry.