Supporting a person-centred approach in clinical guidelines. A position paper of the Allied Health Community - Guidelines International Network (G-I-N)

The Wall of Silence: Perceived Barriers to Gender-Based Violence Disclosure among Women in the Perinatal Period

STUDY BACKGROUND

Gender-based violence is a global concern. The perinatal period is a crucial time for early identification of the harmful impact of violence on the well-being of both mothers and infants. However, it has been observed that many women choose not to disclose their experiences to their healthcare providers.

PURPOSE

To gain insight into this issue, a study was conducted to explore the perspectives of both survivors and healthcare providers regarding the barriers to disclosure.

METHODS

Through the utilization of a thematic analysis approach, a total of 28 interviews were conducted, involving 12 survivors and 16 healthcare providers.

RESULTS

Data analysis revealed barriers to disclosure at the individual, community, and healthcare system levels.

CONCLUSION

Health-care providers have a pivotal role in creating an atmosphere where women are encouraged to break the silence and a paradigm shift in the health system approach towards GBV is necessary.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review

BACKGROUND

Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs.

METHODS

We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria.

RESULTS

We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries.

CONCLUSION

We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level III.

"At the time I only wanted to relieve stress": Exploring motivation for behaviour change in long-term hypnotic users

Background

Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model.

Aim

Exploring primary care patients' views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework.

Design and setting

A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021.

Method

Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method.

Results

The success of discontinuation interventions does not solely rely on patients' spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users.

Conclusion

Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

A systematic review on clinical guidelines of home health care in heart failure patients

BACKGROUND

"Guidelines for the care of heart failure patients at home support safe and effective evidence-based practice. The aims of the present study were: [1] to identify guidelines addressing the care at home for adults with heart failure and [2] evaluate the quality of the guidelines and the extent to which they address eight components of home-based HF disease management."

METHODS

A systematic review was conducted of articles published between 1st of January 2000 to 17th of May 2021 using the databases of PubMed, Web of Science, Scopus, Embase, Cochrane, and nine specific websites for guideline development organisations. Clinical guidelines for HF patients with recommendations relevant to care provision at home were included. The results were reported according to the Preferred Reporting Items for Systematic Reviews (PRISMA-2020) criteria. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation-II (AGREE-II) by two authors independently. Guidelines were evaluated for their coverage of eight components of HF care at home, consisting of integration, multi-disciplinary care, continuity of care, optimized treatment, patient education, patient and partner participation, care plans with clear goals of care, self-care management and palliative care.

RESULTS

Ten HF guidelines, including two nursing-focused guidelines and eight general guidelines were extracted from 280 studies. After evaluation of quality by AGREE-II, two guidelines obtained the highest score: "NICE" and the "Adapting HF guideline for nursing care in home health care settings. Five guidelines addressed all eight components of care at home while the others had six or seven.

CONCLUSIONS

This systematic review identified ten guidelines addressing care at home for patients with HF. The highest quality guidelines most relevant to the care at home of patients with HF are the "NICE" and "Adapting HF guideline for nursing care in home health care settings" and would be most appropriate for use by home healthcare nurses.

[The impact of primary prevention programs of dental diseases on the main trends in the development of dental services]

The vision of the global strategy on oral health is universal health coverage for oral health for all individuals and communities by 2030, enabling them to enjoy the highest attainable state of oral health and contributing to healthy and productive lives (WHO, 2022). To achieve this goal, it is necessary to ensure the development of the dental care system in Russia on the basis of primary prevention of dental diseases.

OBJECTIVE

Analysis of the methodology for the development, implementation and evaluation of programs for the primary prevention of dental diseases and their impact on the main trends in the development of dental services.

MATERIAL AND METHODS

The main research methods were search for publications, analysis and systematization of information on the methodology for developing, implementing and evaluating programs for the primary prevention of dental diseases.

RESULTS

Despite the single main goal of dental disease prevention programs, the analysis of the methodology of their construction and implementation must be carried out considering their impact on the main trends in the development of dental services.

CONCLUSIONS

The main directions of development of the methodology for the development, implementation, and evaluation of primary prevention programs of dental diseases should include the use of indicators of oral health recognized by the international community, which allow us to trace the degree of their influence on the development of the system of dental care.

Community mental health interventions for people with major depressive disorder: A scoping review

People with major depressive disorder continue to be marred by chronically pernicious yet preventable outcomes in the biopsychosocial aspects. With the reallocation of healthcare resources towards the fight against the coronavirus 2019 pandemic, much emphasis has been placed on existing community mental health interventions to ameliorate the disruption of mental health services. Moreover, the recent propulsion of community mental health services by the World Health Organization Mental Health Action Plan 2013-2030 ignited the need to bolster existing community interventions by providing comprehensive, responsive and integrated mental healthcare. The enhanced emphasis on mental healthcare in the community and the heightened demands of people with major depressive disorder underscores the need to explore the current state of community mental health interventions. This scoping review examined 51 primary studies published from year 2010 to 2020 using Arskey & O'Malley's five-stage framework and provided an overview of the impact of existing community mental health interventions for people with major depressive disorder. Findings using thematic analysis have recommended the adoption of person-centred community mental healthcare via the biopsychosocial approach for people with major depressive disorder. Enablers of community mental health interventions were driven by culturally appropriate care and augmented by technology-driven modalities. Challenges and gaps of community mental health interventions include the perpetuation of stigma and misconception, complex demands of persons with major depressive disorder and lack of holistic and long-term outcomes. Given the impact of major depressive disorder on the various biopsychosocial aspects, it is envisioned that our insights into the enablers and barriers of community mental health interventions will guide prospective interdisciplinary and nurse-led interventions in holistically improving the care of persons with major depressive disorder in the community settings.

Interrater reliability of the BelRAI Social Supplement in Flanders, Belgium: Simultaneous rating of community-dwelling adults with care needs during COVID-19

Background

The BelRAI Screener is a short-form assessment consolidating internationally validated interRAI items focusing on physical and psychological aspects of functioning and problems with activities of daily living. It was fully implemented in the Flemish home care setting as of June 2021. In a biopsychosocial model for developing a personalized and effective care plan social and contextual aspects are considered equally important to biomedical ones. Thus, a social supplement to the BelRAI Screener was collaboratively developed with stakeholders and tested to gather additional information on the social context of community-dwelling adults with care needs.

Objective and methods

To examine the interrater reliability of the BelRAI Social Supplement in Flanders, Belgium, an observational study was conducted using a convenience sample. The method of simultaneous rating was used due to strict COVID-19 guidelines at the time and to minimize assessment burden. Fifty two community-dwelling adults requesting home care support were simultaneously assessed by two independent assessors during home visits. Interrater reliability was tested on all 80 items of the BelRAI Social Supplement using observed agreement, kappa coefficients, and intraclass correlation coefficients.

Results

The kappa mean (0.74) and median (0.79) values for nominal items, show substantial agreement, while the kappa mean and median values for ordinal items were 0.81 and 0.90, which correspond to almost perfect agreement. Following the traditional cut-off points for the interpretation of the kappa statistic, reliability was almost perfect (κ > 0.81) for 49% of all items, substantial (0.60 < κ ≤ 0.80) for 33%, moderate (0.40 < κ ≤ 0.60) for 8%, and poor (κ < 0.40) for 10%. The majority of items with poor kappa value, showed a high observed agreement, reflecting homogeneity of the sample rather than poor agreement.

Conclusion

The strength of kappa agreement for the items in this version of the BelRAI Social Supplement is generally substantial to almost perfect, with high proportions of observed agreement. COVID-19 restrictions had a large impact on the planning and execution of the home visits. A final optimization of the instrument and accompanying manual according to the findings will result in an improved version ready for nation-wide implementation.

Knowledge and use of the International Classification of Functioning, disability and health (ICF) and ICF Core Sets for musculoskeletal conditions among saudi physical therapists

BACKGROUND

The International Classification of Functioning, Disability, and Health (ICF) provides a coherent biopsychosocial view of health states. The ICF Core Sets were developed to facilitate and encourage the use of the ICF in clinical practice and research.

OBJECTIVE

To examine the level of knowledge and use of the ICF and ICF Core Sets for musculoskeletal conditions among Saudi physical therapists.

DESIGN

Cross-sectional study.

METHOD

We approached Saudi physical therapists (PTs) involved in managing patients with musculoskeletal conditions. Data were collected through an electronic survey consisting of multiple-choice questions related to the knowledge of the ICF, general ICF Core Sets and ICF Core Sets for musculoskeletal conditions.

RESULTS

A total of 203 PTs participated in this study. Seventy percent of PTs knew about the meaning of ICF, but only 33% recognized aspects of the ICF. For the osteoarthritis (OA) ICF Core Set, 71.9% had poor knowledge, and for the low back pain (LBP) ICF Core Set, 61.8% had poor knowledge.

CONCLUSIONS

The Saudi PTs surveyed in this study had a good level of knowledge about the meaning of the ICF; however, this knowledge appeared to be limited when they were asked about aspects of the ICF. They had poor knowledge of musculoskeletal ICF Core Sets but seemed to be more familiar with the LBP ICF Core Set compared to the OA ICF Core Set.

Symptoms of depression and catastrophic thinking attenuate the relationship of pain intensity and magnitude of incapability with fracture severity

OBJECTIVE

The relative association of pain intensity and magnitude of incapability with pathophysiology, accounting for psychological factors, is incompletely understood. Using moderation analysis, we assessed the association of pain intensity and magnitude of incapability (dependent variables) with fracture severity (independent variable) and the influence of symptoms of depression and catastrophic thinking (moderators) at early and later stages of recovery.

METHODS

A cohort of 731 patients recovering from a shoulder, elbow, or wrist fracture, completed self-reported measures of pain intensity, upper extremity capability, symptoms of depression, and catastrophic thinking between 2 and 4 weeks after injury and again between 6 and 9 months after injury. Fracture severity was rated by clinicians, and we used multivariable regression analysis to examine interaction effects of fracture severity, depression, catastrophic thinking, pain intensity, and magnitude of incapability at early and later stages of recovery.

RESULTS

Symptoms of depression and catastrophic thinking attenuate the relationship between pain intensity and fracture severity at earlier and later stages of recovery. Symptoms of depression and catastrophic thinking also attenuate the relationship between the magnitude of incapability and fracture severity, but only at early stages of recovery.

CONCLUSION

The relative divergence of pain intensity and magnitude of incapability from the level of fracture severity due to the moderating effects of unhelpful thinking and distress, signals a benefit to anticipating mental health opportunities during recovery after fracture. Fracture management can incorporate measures of unhelpful thinking and symptoms of distress to better address these opportunities and ensure comprehensive optimization of recovery.

LEVEL OF EVIDENCE

Level IIc, prognostic.

Mapping Hospital-Based Lactation Care Provided to Bereaved Mothers: A Basis for Quality Improvement

Objective: The study aimed to identify and map the factors that shape the delivery of hospital-based lactation care for bereaved mothers to inform quality improvement initiatives targeting hospital-based lactation care. Methods: Focus groups and interviews were conducted at three large hospitals in Australia with 113 health professionals including obstetricians, neonatologists, midwives, neonatal nurses, lactation consultants, social workers or pastoral care workers, Human Milk Bank (HMB) staff, and perinatal bereavement nurses. Thematic and interactional data analysis identified the nature, scope, and pattern of bereavement lactation care. Results: A bereaved lactation care pathway was generated from health professionals' reports. Bereaved lactation care, if provided, was limited to brief encounters aimed at facilitating lactation suppression. The type of lactation care offered, and any exploration of the variable biopsychosocial significance of lactation after infant death, was conditional on (i) availability of health professionals with suitable awareness, knowledge, capacity, confidence, and comfort to discuss lactation; (ii) hospital culture and mode of suppression primarily practiced; (iii) mother's breast milk being visible to hospital staff; (iv) mother expressing interest in expanded lactation management options; (v) availability of, and eligibility to, donate to a HMB; and (vi) support beyond the hospital setting being facilitated. Conclusion: Mothers should be presented with the full array of lactation management options available after stillbirth or infant death. Inclusion of evidence-based, biopsychosocial and patient-centered approaches to lactation care is urgently required in health professionals' bereavement training and in the policies of hospitals and HMBs.

Rasch Analysis of Self-Reported Adherence to Patient-Centered Physical Therapy Scale among Japanese Physical Therapists: Cross-Sectional Study

This study primarily aimed to develop a shorter version of the self-reported adherence to patient-centered physical therapy (s-SAPCPTS) by using Rasch analysis and secondarily aimed to preliminarily investigate the relationship between the s-SAPCPTS scores and demographics (i.e., age, sex, final academic degree (non-postgraduate degrees or postgraduate degrees), and practice environment). In an online anonymous survey, 110 Japanese physical therapists completed the self-reported adherence to patient-centered physical therapy and provided data on their demographics. Through the Rasch analysis, items were excluded in a stepwise manner, until certain pre-established criteria of the unidimensionality were satisfied. Subsequently, a conversion table for the Rasch score was developed. Furthermore, multiple regression analysis was conducted by using the independent variables age, sex, and final academic degree. Using the Kruskal-Wallis test, we compared the Rasch s-SAPCPTS scores among four practice environments. Consequently, the seven-item s-SAPCPTS was developed by excluding seven items through the Rasch analysis. Postgraduate degree was a statistically significant contributing factor for Rasch s-SAPCPTS scores (p = 0.038, β = 0.20). The Kruskal-Wallis test demonstrated statistically significant differences in the Rasch s-SAPCPTS scores among the four practice environments (p = 0.006). In conclusion, the seven-item s-SAPCPTS was developed with the preliminary evidence of construct validity. It was also found that the final academic degree and practice environment could be the contributing factors of s-SAPCPTS scores.

Towards a standardized approach of assessing social context of persons receiving home care in Flanders, Belgium: the development and test of a social supplement to the interRAI instruments

BACKGROUND

Apart from a person's physical functioning, the early identification of social context indicators which affect patient outcomes - such as environmental and psychosocial issues - is key for high quality and comprehensive care at home. During a home care assessment, a person's biomedical and functional problems are typically considered. Harder to define concepts, such as psychosocial well-being or living arrangements, are not routinely documented, even though research shows they also affect functioning and health outcomes. The purpose of this study is to develop and test a concise, integrated assessment (BelRAI Social Supplement) that evaluates these social context indicators for persons receiving home care to complement existing interRAI- instruments.

METHODS

The development of the BelRAI Social Supplement is a multi-stage process, based upon the revised MRC-framework, involving both qualitative and quantitative research with stakeholders such as; clients, informal caregivers, care professionals and policy makers. The developmental process encompasses four stages: (I) item generation based on multiple methods and content validation by a panel of stakeholders (II) assessing feasibility and piloting methods, (III) early evaluation, and (IV) final evaluation. Stage II and III are covered in this paper.

RESULTS

During Stages I and II, a testable version of the BelRAI Social Supplement was developed in an iterative process. In Stage III, 100 care professionals assessed 743 individuals receiving home care in Flanders between December 2018 and December 2019. Using inter-item correlation matrixes, frequency distributions and regular feedback from the participants, the BelRAI Social Supplement was improved and prepared for Stage IV. The updated version of the instrument consists of four main sections: (1) environmental assessment; (2) civic engagement; (3) psychosocial well-being; and (4) informal care and support. In total, the BelRAI Social Supplement contains a maximum of 76 items.

CONCLUSIONS

The BelRAI Social Supplement was reviewed and shortened in close collaboration with care professionals and other experts in Flanders. This study resulted in an instrument that documents need-to-know social context determinants of home dwelling adults.

A descriptive analysis of clinical application of patient-reported outcome measures and screening tools for low back pain patients in US chiropractic teaching institutions

OBJECTIVE

To describe the clinical use of patient-reported outcome measures (PROMs) and screening tools (STs) for low back pain (LBP) in clinics of chiropractic teaching institutions in the United States.

METHODS

A descriptive analysis was completed with data collection achieved between June 2018 and March 2019. PROMs/STs were classified as disability/functional measures, pain measures, psychosocial measures, and other measures. Frequencies of use of PROM/ST instruments were calculated.

RESULTS

Representatives from 18 of 19 chiropractic institutions (94.75%) provided a description of PROM/ST use for LBP in their teaching clinics. Seventeen institutions (94.4%) reported the routine clinical use of PROMs/STs for LBP. Disability/functional measures were the most common type of instruments used, followed by pain measures, psychosocial measures, and others. The 4 most common individual PROMs/STs reported were (1) Oswestry Disability Index, (2) a variation of a pain rating scale, (3) Keele STarT Back Tool, and (4) Patient Specific Functional Scale. Six out of 18 (33%) institutions reported the use of a PROM/ST specifically designed to focus on psychosocial influences.

CONCLUSION

Most chiropractic institution teaching clinics in the United States reported the clinical use of PROMs/STs for patients presenting with LBP. This mirrors trends in chiropractic literature of increasing use of PROMs/STs. A minority of institutions described the clinical use of a PROM/ST specifically designed to detect psychosocial influences.

Developing a Standard Set of Patient-centred Outcomes for Adult Oral Health - An International, Cross-disciplinary Consensus

Objective

To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health.

Materials and methods

An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers.

Results

The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered.

Conclusion

In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.

What are the Relevant Outcomes of the Periodic Health Examination? A Comparison of Citizens' and Experts' Ratings

PURPOSE

Despite evidence from clinical guideline development that physicians and patients show discordance in what they consider important in outcome selection and prioritization, it is unclear to what extent outcome preferences are concordant between experts and citizens when it comes to the context of primary prevention. Therefore, the objective of this study was to assess whether expert judgments about the importance of beneficial and harmful outcomes differ from citizen preferences when considering intervention options for a periodic health examination (PHE) program.

PARTICIPANTS AND METHODS

We conducted an online survey using a modified Delphi approach. The target population for the survey consisted of citizens who had attended the PHE (n=18) and experts who made evidence-based recommendations (n=11). Citizens and experts assigned a score on a 9-point Likert scale for each outcome of 14 interventions. We analyzed the intragroup agreement based on Krippendorff's alpha and the intergroup agreement using the cube root product measure (CRPm). We further tested for significant differences between the groups using the Mann U-test.

RESULTS

Agreements within the groups of citizens and experts varied across the interventions and tended to be poor (α ≤0 to 0.20) or fair (α = 0.21 to 0.40), with three exceptions showing moderate agreement (α = 0.44 to 0.55). The agreements between the citizens and experts across the interventions was fair (CRPm = 0.28) during the first Delphi rating round. The mean differences between the citizens and experts on the Likert scale ranged from 0.0 to 3.8 during the first rating round and from 0.0 to 3.3 during the second. Across interventions, the citizens rated the outcomes as more important than the experts did (p<0.01). Individual participants' ratings varied substantially.

CONCLUSION

Because experts generally underestimated the outcomes' importance to citizens, the involvement of citizens in guideline panels for preventive services is important.

Inpatients' Perception of Patient-Centered Care in Guangdong Province, China: A Cross-Sectional Study

This study aimed to investigate the perceptions of patient-centered care (PCC) among inpatients in Guangdong Province (GD), China. Based on these perspectives, we sought to understand existing PCC practices in medical institutions and identify the impacts of inpatients’ sociodemographic status on their perceived PCC. A self-developed PCC questionnaire was used to investigate inpatients’ perceptions of PCC. A cross-sectional survey was conducted in nine tertiary-level hospitals across five cities in GD. Descriptive statistics was used to describe the levels of PCC in GD. The differences in PCC levels across different sociodemographic groups were assessed using analysis of variance and multivariate linear regression. Valid responses were provided by 1863 inpatients. The mean overall PCC score was 8.58 (standard deviation [SD] = 1.36); inpatients from the Pearl River Delta and eastern GD area reported significantly higher scores than those from western and northern GD area (P<.01). Inpatients from rural areas tended to report lower PCC scores than their urban counterparts. Among the PCC questionnaire sub-domains, inpatients scored highest and lowest in “patient experience” (mean = 8.96, SD = 1.34) and “medical insurance” (mean = 7.93, SD = 2.05), respectively. This study provided a comprehensive overview of inpatients’ perceptions of PCC in the public healthcare system in GD, China. Our findings highlighted that a majority of inpatients were satisfied with the PCC in public healthcare system; however, a significant discrepancy between inpatients with different sociodemographic status remained.

A qualitative exploration of the uses of the International Classification of Functioning, Disability and Health at an inpatient neurorehabilitation facility in the Western Cape, South Africa

Purpose of the study: The aim of the study was to describe how healthcare professionals at a neurorehabilitation facility currently use the International Classification of Functioning, Disability and Health (ICF) and to identify further possibilities for its future use.Methods: The study followed an interpretive description approach. Data were collected through four focus group discussions with 21 participants, all health care practitioners, at the study facility. Thematic analysis was conducted by coding the transcripts and generating themes.Findings: Three themes were generated: (1) Current use and gaps in use of the ICF, (2) a non-conducive environment and (3) using the ICF to facilitate holistic, patient-centred management. Current use of the ICF was limited. Gaps in use of the ICF was especially evident in goal setting practices. Goals were generic in nature and did not address participation and the environment. A lack of knowledge, debilitating interpersonal relationships and an unsupportive organisational culture created an environment non-conducive to the implementation of the ICF. Participants felt that the ICF can assist them to work more patient-centred.Conclusion: Participants perceived that the ICF has the potential to improve service delivery at the facility. The implementation process must be well structured, focus on practical use and be supported through an enabling environment created by management.IMPLICATIONS FOR REHABILITATIONThe ICF is not being optimally used in clinical rehabilitation practice, however healthcare practitioners perceive the ICF to have the potential to improve rehabilitation service delivery.Concerted action is required at institutional, interpersonal and individual level to create a conducive environment that facilitates the use of the ICF during rehabilitation service delivery.The ICF can be used to construct a team assessment document that promotes patient-centred goal setting and improves interdisciplinary communication.

Implementation of a Personalized, Cost-Effective Physical Therapy Approach (Coach2Move) for Older Adults: Barriers and Facilitators

Background and Purpose:

This article reports on a recent randomized clinical trial that showed a personalized approach to physical therapy (Coach2Move) by a physical therapist specialized in geriatrics (PTG) to be more cost-effective than usual physical therapy care in people with mobility problems (n = 130, mean age = 78 years).

Methods:

We used an explanatory mixed-methods sequential design alongside the randomized clinical trial to gain insight into (a) the contrast between the 2 interventions, (b) the fidelity of the Coach2Move delivery; (c) PTGs' experiences of Coach2Move; and (d) possible barriers and facilitators for future implementation. The study included 13 PTGs educated in the strategy and 13 physical therapists with expertise in geriatrics delivering the usual care. In total, 106 medical records were available for assessment: 57 (85%) Coach2Move, 49 (75%) usual care. Quantitative process indicators were used to analyze electronic medical records to determine contrasts in the phases of clinical reasoning. The fidelity of the delivery was tested using indicator scores focusing on 4 key elements of Coach2Move. In-depth interviews with Coach2Move therapists were thematically analyzed to explore experiences and facilitators/barriers related to implementation.

Results and Discussion:

Indicator scores showed significant and clinically relevant contrasts in all phases of clinical reasoning, with consistently higher scores among PTGs, except for the treatment plan. Moreover, the fidelity of Coach2Move delivery was more than 70% in all phases, except the evaluation phase (53%). Experiences of Coach2Move were positive. In particular, extended intake allowing motivational interviewing, physical examination and an in-depth problem analysis, and shared goal setting were considered valuable. Facilitators for implementation were the addition of a Coach2Move medical record, frequent coaching by the researcher, and readiness to change in the therapist. Barriers were (1) having to use 2 parallel electronic medical record systems, (2) having to clear the calendar to schedule an intake of 90 minutes, (3) fear of losing income, (4) the sense that patients do not want to change their lifestyle, and (5) not acknowledging that increasing physical activity is an important goal for older adults with mobility problems.

Conclusions:

Physical therapy based on the Coach2Move strategy is substantially different from usual care. Future implementation should focus on increasing regular evaluation and feedback, taking into account individuals' contextual factors, and improving organizational facilities while mitigating income loss.

Best Practice Principles When Working With Individuals With Intellectual Disability and Comorbid Mental Health Concerns

Working with individuals with dual disabilities can be a complex process in the presence of limited evidence base to guide clinical practice. The aims of this qualitative study were to investigate perceptions of best practices of Australian psychologists who work with this specialist population. Thirty-eight Australian psychologists working in the intellectual disability field participated in eight semistructured focus groups. Perceptions of evidence-based practice for individuals with intellectual disabilities and in relation to mental health assessment were explored. Psychologists demonstrated resourcefulness in adapting to limits in available evidence-based practice and in modifying mainstream practice to suit the needs of individuals with dual disabilities. Findings suggest the necessity of practice-based evidence in contributing to the evidence base, and person-centered approaches in relation to best practice for people with intellectual disabilities. Implications for strengthening psychologists' clinical competency and bridging the research and practice gap are discussed.

The impact of a training programme incorporating the conceptual framework of the International Classification of Functioning (ICF) on behaviour regarding interprofessional practice in Rwandan health professionals: A cluster randomized control trial

BACKGROUND

Appropriate collaboration between health professionals (HP) can reduce medical errors, enhance the spread of critical information, and assist in interpretation of health information resulting in improved patient care. The International Classification of Functioning, Disability and Health (ICF) may provide a useful conceptual framework to facilitate better interprofessional practice.

PURPOSE

To determine whether a training programme based on the ICF framework resulted in improved interprofessional behaviour among HPs in Rwanda.

METHODOLOGY

A cluster randomised control trial was used. Four district hospitals were randomly allocated to receive either a day's training in interprofessional practice based on the ICF framework (experimental) or a short talk and a booklet on the topic (control). A total of 203 participants included medical doctors, nurses, and other HPs took part in this study. Simple random sampling was used to select the hospital records of 200 patients discharged from relevant wards at both the experimental and control hospitals at baseline and at two, four and six months after training (800 patients' records from each group). A self-designed checklist has undergone some validation and was based on the ICF conceptual model was used to audit the quality of information included in the patients' records. Ethical approval was obtained from the relevant authorities.

RESULTS

The demographic and medical profile of the patients in the two sets was equivalent. An ANOVA and post-hoc Tukey test indicated the mean number of items correctly filled in was not significant at baseline (p = 0.424) but the difference was significant (p < .001) for the post-intervention scores at two, four and six months. The control group scores did not improve over time. The improved behavior was still evident at six months although it had begun to decay.

CONCLUSION

Behaviour change as evidenced by more comprehensive recording of patient management can result from a well-structured training programme. The ICF appeared to provide a common language and facilitate HPs interaction and patient management plans.

IMPLICATION

The ICF provided an effective conceptual framework to structure the content of the training and the audit tool. It is recommended that the framework be used to facilitate interprofessional education and practice in Rwanda and that the training approach may be applicable to other health care contexts.

Relationship Between Magnitude of Limitations and Patient Experience During Recovery from Upper-Extremity Fracture

The relationship between the magnitude of limitations (measured by patient-reported outcome measures, or PROMs) and satisfaction with care providers and hospital services (measured by patient-reported experience measures, or PREMs) over the course of recovery after injury is unclear. The purpose of this study was to assess the relationship between a range of PROMs and 2 PREMs at 3 time points (initial office visit within a week, 2 to 4 weeks, and 6 to 9 months) after shoulder, elbow, and wrist fractures.

Mental health assessment in rehabilitation: a descriptive study through an international internet survey

This cross-sectional study assessed international rehabilitation practitioners' views of mental health assessment (MHA), related specifically to assessment tools and needs in the field. We delivered an anonymous web-based survey capturing rehabilitation practioners' perspectives on MHA practices, assessment tools, and needs through the American Congress of Rehabilitation Medicine in the USA and through national rehabilitation networks in Finland and Norway. Altogether, 355 rehabilitation professionals answered the survey. Unmet MHA needs, most often attributed to insufficient time (112/269 responders), were recognized among rehabilitation professionals irrespective of the country of practice. When professional experience was weighed against barriers to conducting MHA, cost was statistically significantly linked to professional experience, with those with less experience viewing cost more as a barrier (P=0.019). Rehabilitation professionals from different professions, in different countries, and working with a variety of clinical populations recognize defined barriers to MHA in rehabilitation.

South African primary health care allied health clinical practice guidelines: the big picture

BACKGROUND

Good quality clinical practice guidelines (CPGs) are a vehicle to implementing evidence into allied health (AH) care. This paper reports on the current 'state of play' of CPGs in a lower-to-middle-income country (South Africa), where primary healthcare (PHC) AH activities face significant challenges in terms of ensuring quality service delivery in the face of huge PHC need.

METHODS

A qualitative study was conducted, using semi-structured interviews with purposively-sampled individuals involved in AH PHC CPGs in South Africa. They included national and state government policy-makers, academics and educators, service managers, clinicians, representatives of professional associations, technical writers, and members of informal professional networks. The interview data was transcribed and de-identified, and analysed descriptively by hand-coding. The COREQ statement guided study conduct and reporting. A framework to guide research in other countries into perspectives of AH PHC CPG activities was established.

RESULTS

Of the 32 invited, 29 people participated: of these 25 were interviewed and four provided meeting notes. Most participants had multiple professional roles, being engaged concurrently in clinical practice, academia, professional associations and / or government. Key themes comprised Players (sub-themes of sampling frame, participants, advice, role players and collaboration); Guidance (sub-themes of nomenclature, drivers, purpose, evidence sources) and Role of AH in PHC (sub-themes of discipline groupings, disability and rehabilitation, AH recognition).

CONCLUSION

There was consistently-expressed desire for quality guidance to support better quality AH PHC activities around the country. However no international CPGs were used, and there were no South African CPGs specific to local PHC AH practice. The guidance gap was filled by non-evidence-based documents produced often without training, to deal with specific clinical situations. This led to frustration, duplication and fragmentation of effort, confusing nomenclature, and an urgent need for standardised and agreed guidance. We provided a standardised framework to capture perspectives on CPGs activities in other AH PHC settings.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE

Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment.

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.

The biopsychosocial model of illness: a model whose time has come

The biopsychosocial model outlined in Engel’s classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel’s call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation’s International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.

From the EBM pyramid to the Greek temple: a new conceptual approach to Guidelines as implementation tools in mental health

Guideline methods to develop recommendations dedicate most effort around organising discovery and corroboration knowledge following the evidence-based medicine (EBM) framework. Guidelines typically use a single dimension of information, and generally discard contextual evidence and formal expert knowledge and consumer's experiences in the process. In recognition of the limitations of guidelines in complex cases, complex interventions and systems research, there has been significant effort to develop new tools, guides, resources and structures to use alongside EBM methods of guideline development. In addition to these advances, a new framework based on the philosophy of science is required. Guidelines should be defined as implementation decision support tools for improving the decision-making process in real-world practice and not only as a procedure to optimise the knowledge base of scientific discovery and corroboration. A shift from the model of the EBM pyramid of corroboration of evidence to the use of broader multi-domain perspective graphically depicted as 'Greek temple' could be considered. This model takes into account the different stages of scientific knowledge (discovery, corroboration and implementation), the sources of knowledge relevant to guideline development (experimental, observational, contextual, expert-based and experiential); their underlying inference mechanisms (deduction, induction, abduction, means-end inferences) and a more precise definition of evidence and related terms. The applicability of this broader approach is presented for the development of the Canadian Consensus Guidelines for the Primary Care of People with Developmental Disabilities.

Determinants of sick-leave length: still limited to diagnosis elements

PURPOSE

Sickness certification implies that a health problem impairs ability to work. However, its assessment is seldom performed by physicians. Our objective was, therefore, to assess the specific influence of functional and environmental limitations on the length of sick-leave prescriptions.

METHOD

We conducted a cross-sectional study in French general teaching practices and recorded 353 initial sick-leave certifications. For each of them, the functional and environmental limitations were collected using the ATCIF questionnaire, derived from the International Classification of Functioning. Data analysis was based on a linear regression multivariate model.

RESULTS

Among the functional limitations, "pain" was the main body function impairment (22% of impairments) and "mobility" the main activity limitation (48%). An environmental barrier was identified in 39% of sick-listed patients, mainly relating to "products and technology" (20%), which refers to workplace factors. The prescription was longer in cases of activity limitations relating to "mobility" and in cases of environmental barriers relating to "products and technology". The multivariate model explained 27% of the variability of sick-leave length through diagnosis elements and only 7% through functional and contextual elements.

CONCLUSION

In sick-leave prescription, a functional and contextual approach, in addition to the traditional diagnosis-based approach, could better support patients' shared understanding and follow-up, and accountability towards health authorities. Implication for Rehabilitation Although sickness certification implies that a health problem impairs ability to work, decision on sick-leave length in general practice is primarily based on diagnosis. A more functional and contextual approach could better support patients' and other health professionals' shared understanding and follow-up, and accountability towards health authorities. Such evolution requires a change of paradigm in medical education, and the way of reasoning of healthcare professionals.

User involvement in the implementation of clinical guidelines for common mental health disorders: a review and compilation of strategies and resources

BACKGROUND

There is now broad consensus regarding the importance of involving users in the process of implementing guidelines. Few studies, however, have addressed this issue, let alone the implementation of guidelines for common mental health disorders. The aim of this study is to compile and describe implementation strategies and resources related to common clinical mental health disorders targeted at service users.

METHODS

The literature was reviewed and resources for the implementation of clinical guidelines were compiled using the PRISMA model. A mixed qualitative and quantitative analysis was performed based on a series of categories developed ad hoc.

RESULTS

A total of 263 items were included in the preliminary analysis and 64 implementation resources aimed at users were analysed in depth. A wide variety of types, sources and formats were identified, including guides (40%), websites (29%), videos and leaflets, as well as instruments for the implementation of strategies regarding information and education (64%), self-care, or users' assessment of service quality.

CONCLUSIONS

The results reveal the need to establish clear criteria for assessing the quality of implementation materials in general and standardising systems to classify user-targeted strategies. The compilation and description of key elements of strategies and resources for users can be of interest in designing materials and specific actions for this target audience, as well as improving the implementation of clinical guidelines.

Assessing subjective quality of life domains after multiple sclerosis diagnosis disclosure

BACKGROUND AND OBJECTIVE

An investigation of the domains Italian patients with multiple sclerosis (MS) named as constituting their quality of life over time.

DESIGN

We assessed, in 68 patients, QoL domains using the Schedule for the Evaluation of Individual QoL: (a) before MS diagnosis disclosure, (b) thirty days after disclosure, and (c) after one and (d) four years' follow-up.

RESULTS

The life domains most frequently named by patients were as follows: Family, Work and Finance, Hobbies, Health, Relationship with Friends and Job Effectiveness. Only Health and Job Effectiveness domains varied with time. The Health domain became a critical dimension when MS diagnosis was revealed. In addition, patients tended to be more satisfied with their health after disclosure compared to pre-diagnosis. Job Effectiveness seemed to be an important aspect until 1 year after diagnosis disclosure, but it tended to become less crucial over time. Family seems to be the most important domain over time, and psychological adaptation to MS seems to be characterized by a reconceptualization of aspects that revolve around oneself, such as professional success, rather than relational or affective factors.

CONCLUSIONS

Evaluating the most relevant life domains for patients and their alteration over time may provide practitioners with an important tool in making health-related decisions, thus improving health outcomes and QoL.