Understanding usual care in randomised controlled trials of complex interventions: A multi-method approach

eMPower: An online Mind-body wellness Program for adults living with chronic health conditions: A three-armed randomized controlled trial protocol

BACKGROUND

Symptoms of depression and anxiety are prevalent among adults with chronic health conditions, contributing to reduced quality of life, morbidity, and mortality. Mind-body wellness interventions (i.e. psychology programming, mindful movement, breathwork, meditation) may impact mental health symptoms, with online delivery offering access and scalability. Whether online mind-body wellness interventions are effective in improving patient outcomes across a broad range of chronic conditions remains uncertain.

METHODS

This three-armed, pragmatic, randomized controlled trial will use a nested mixed methods approach to assess the effectiveness of an online mind-body wellness intervention (eMPower), offered at two levels of personnel support, on symptoms of anxiety and depression in adults with chronic health conditions. Inclusion criteria require a self-reported chronic condition and access to an internet-connected device. Eligible participants will be randomized 1:1:1 to [1] waitlist control; [2] eMPower; [3] eMPower + weekly 1-to-1 check-in. The primary analysis will compare the Hospital and Anxiety Depression Scale (HADS) total score between eMPower + weekly 1-to-1 check-in versus controls, with secondary and exploratory outcomes including HADS subscales, health-related quality of life, fatigue, program engagement, and frailty.

CONCLUSION

With online intervention delivery, a range of outcomes, mixed method evaluation, and automated intervention tracking, findings are anticipated to enhance our understanding of how individuals living with chronic health conditions engage with and are impacted by online mind-body wellness programming. Six hundred and fifty-six participants have been enrolled as of April 5, 2024, and 598 patients have completed 12-week follow-up.

Current situation, strengths and problems in intra- and interprofessional collaboration in German nursing homes - A holistic multiple case study

BACKGROUND

The increasing care complexity of nursing home residents living with dementia requires new care models that strengthen professional collaboration. To contribute to the sustainable implementation of new care models, it is important that they are linked to the care reality. However, little is known about intra- and interprofessional organization and provision of care in German nursing homes. Therefore, the aim of this study was to explore the current care situation, problems and strengths regarding intra- and interprofessional collaboration in the care of residents living with dementia.

METHODS

We conducted a holistic multiple case study. The individual care units in which residents living with dementia are cared for were defined as cases. The context was built by the respective nursing homes and their regional affiliation to the federal state of North Rhine-Westphalia. We used qualitative face-to-face interviews, documents and context questionnaires for data collection. The different sources of evidence served to capture complementary perspectives and to validate the findings. First, the collected qualitative data were analyzed using deductive-inductive content analysis. Second, similarities and differences between the cases were identified to elaborate case-specific and cross-case patterns and themes. The reporting followed the EQUATOR reporting guideline for organizational case studies.

RESULTS

We included four care units comprising 21 professionals (nurses, physicians, social worker, physiotherapist, pharmacist) and 14 relatives of residents living with dementia. The analysis revealed four categories to describe current intra- and interprofessional collaboration in all cases: actors and their roles, service delivery, coordination and governance, and communication channel. Moreover, we identified three categories that relate to the strengths and problems of intra- and interprofessional collaboration in all cases: role understanding, teamwork, and communication and exchange. Although we examined similar care units, we found differences in the realization of professional collaboration and resulting problems and strengths that are connected to the organizational contexts and strategies used.

CONCLUSIONS

Even though professional collaboration follows given patterns; these patterns do differ context-specifically and are perceived as problematic and fragmentary. Therefore, the identified differences and problems in collaboration need to be addressed in future research to develop and successfully implement tailored innovative care models.

COMPAR-EU Recommendations on Self-Management Interventions in Type 2 Diabetes Mellitus

Self-management interventions (SMIs) offer a promising approach to actively engage patients in the management of their chronic diseases. Within the scope of the COMPAR-EU project, our goal is to provide evidence-based recommendations for the utilisation and implementation of SMIs in the care of adult individuals with type 2 diabetes mellitus (T2DM). A multidisciplinary panel of experts, utilising a core outcome set (COS), identified critical outcomes and established effect thresholds for each outcome. The panel formulated recommendations using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, a transparent and rigorous framework for developing and presenting the best available evidence for the formulation of recommendations. All recommendations are based on systematic reviews (SR) of the effects and of values and preferences, a contextual analysis, and a cost-effectiveness analysis. The COMPAR-EU panel is in favour of using SMIs rather than usual care (UC) alone (conditional, very low certainty of the evidence). Furthermore, the panel specifically is in favour of using ten selected SMIs, rather than UC alone (conditional, low certainty of the evidence), mostly encompassing education, self-monitoring, and behavioural techniques. The panel acknowledges that, for most SMIs, moderate resource requirements exist, and cost-effectiveness analyses do not distinctly favour either the SMI or UC. Additionally, it recognises that SMIs are likely to enhance equity, deeming them acceptable and feasible for implementation.

What is an "early palliative care" intervention? A scoping review of controlled studies in oncology

INTRODUCTION

Early palliative care (EPC) has been advocated to improve cancer patients' health. However, EPC differs with regard to its elements and target groups. It is not known which parts of EPC contribute to effectiveness for which patient group. This scoping review provides a structured analysis of EPC interventions and outcome measures.

DESIGN

We searched EMBASE, MEDLINE, CINAHL, and CENTRAL up to February 2022. We included randomized controlled trials (RCT), nonrandomized trials, cohort studies (CS), and controlled before-after studies of EPC in adult patients in English, Dutch, and German language. Interventions had to be self-labeled as EPC. Screening and data extraction were performed by two raters. A structured analysis incorporating the TIDieR checklist was performed to describe the elements of the interventions.

RESULTS

We screened 2651 articles, resulting in 40 articles being included: 34 studies were RCT and six studies were CS with a mean sample size of 208 patients. Patients with pancreatic (n = 10) and lung cancer (n = 9) were most often included. Studies reported different reference points for the onset of EPC such as time after diagnosis of incurable cancer (n = 18) or prognosis (n = 9). Thirteen studies provided information about elements of EPC and eight studies about the control intervention. Most frequent elements of EPC were symptom management (n = 28), case management (n = 16), and advance care planning (ACP; n = 15). Most frequently reported outcome measures were health-related quality of life (n = 26), symptom intensity (n = 6), resource use, and the patient's mood (n = 4 each).

CONCLUSION

The elicited heterogeneity of ECP in combination with deficits of reporting are considerable barriers that should be addressed to further develop effective EPC interventions for different groups of cancer patients.

Impact of eHealth education to reduce anemia among school-going adolescent girls in rural Bangladesh: Study protocol of a randomized controlled trial

Adolescent girls are highly vulnerable to developing anemia due to reproductive immaturity, poor personal hygiene, and lack of nutritional intake and health education in rural Bangladesh. Digital health technology is a promising tool to overcome barriers and provide appropriate health guidelines. We aim to evaluate eHealth education's impact and changes in adolescent girls' knowledge, attitude, and practice regarding anemia. A 1:1 parallel randomized control trial was conducted among school-going adolescent girls in rural Bangladesh. A total of 138 anemic (mild and moderate) participants were enrolled. We randomized schools to reduce the health education bias through a simple coin toss technique, then allocated participants to the intervention group (n = 69) and control group (n = 69) by stratified random sampling technique. The intervention group received two online counseling sessions and 8-month eHealth education through mobile phone calls and short message service regarding anemia. The control group received the usual care. The primary endpoint changes the anemic level through changing knowledge, healthy lifestyle behavior, and an iron-rich food dietary plan. Per-protocol analysis will utilize to compare the control and intervention groups using SPSS software. Descriptive statistics (frequencies, percentages, mean, SD) will be employed, and continuous variables will be compared using the t-test/Mann-Whitney test. Two-way analysis of variance will assess outcome variables at baseline, 4 months, and 8 months. The 8-month intervention is designed from May 2022 to February 2023. Participants' age range of 10-14 years was 60.9% in the intervention group and 56.5% in the control group. Among the participants, 89.9% and 88.4% were mild anemic; 11.11 (SD ± 0.80) and 11.06 (SD ± 0.96) were mean hemoglobin in the intervention and control groups, respectively. eHealth education is expected to be an effective way to increase knowledge and healthy behavioral change, which can reduce the anemia burden among adolescent girls.

Healthcare-related factors influencing symptom persistence, deterioration, or improvement in patients with persistent somatic symptoms: A scoping review of European studies

OBJECTIVE

This scoping review explored healthcare-related factors associated with symptom persistence, deterioration, or improvement in patients with persistent somatic symptoms (PSS) across Europe.

METHODS

Articles were systematically searched in PubMed, Web of Science, Cochrane Library, and PsycINFO by combining terms of PSS and healthcare-related factors. Studies published in English, German, Polish, or Dutch between 2000 and 2022 were included. Healthcare-related factors associated with PSS symptom course were investigated, and study quality assessed (Center for Evidence-Based Medicine Checklist, Newcastle-Ottawa Scale).

RESULTS

Of 8386 identified studies, 56 were included in the analysis. A significant knowledge gap was evident, as most studies lacked comprehensive healthcare descriptions with particularly unclear definitions of "treatments as usual" in RCTs. The only extractable healthcare factor according to Andersen's Behavioral Model was the treatment setting. Rates of PSS improvement split by care-levels were 38% in primary, 44% in secondary, 25% in mixed, and 71% in specialized care. Persistence rates were 57%, 50%, 75%, and 29% respectively. Deterioration was observed in 5% of primary and 6% of secondary care studies. Studies were skewed toward the United Kingdom, Germany, and the Netherlands.

CONCLUSIONS

This scoping review shed light on the association between care levels and symptom outcomes in PSS patients. However, limited information in the current studies constrained our exploration of associations with other factors and symptom outcomes. Important aspects, like care availability, referral processes, and insurance coverage, are yet to be elucidated. Addressing these gaps is pivotal for developing targeted treatments across Europe, ultimately enhancing PSS patients' outcomes.

The effect of internet-delivered cognitive behavioral therapy for depression and anxiety on quality of life: A meta-analysis of randomized controlled trials

Although numerous studies have examined the effects of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety on quality of life, no meta-analysis has yet been conducted to integrate the results of these studies. We conducted systematic searches in PubMed, Cochrane, and PsycInfo, which included terms for treatment type, modality of delivery, condition, and main outcome. We included studies that met the following inclusion criteria: (a) randomized controlled trials, (b) patients allocated to some form of the control condition, (c) patients receiving some type of treatment of anxiety and/or depression involving Internet-delivered Cognitive Behavioral Therapy, (d) use of a validated outcome measure assessing the level of quality of life, (e) conducted with adult participants diagnosed with anxiety disorder and/or unipolar depression, (f) papers written in English. We analyzed 40 randomized controlled trials with a total of 4289 participants that met inclusion criteria. The pooled between-group effect size for the quality of life overall score was small (g = 0.35, 95 % CI: 0.26-0.44, p = .0001), favoring iCBT over the control conditions. Regarding the distinct quality of life domains measured by the World Health Organization Quality of Life Assessment, a statistically significant difference between iCBT and control conditions was found only for the physical health domain (g = 0.56, 95 % CI: 0.06-1.07, p = .029), in favor of iCBT. In both cases, heterogeneity was moderate. While the effect on the quality of life is small (the overall quality of life score) to moderate (the physical health domain score), we conclude that iCBT for depression and anxiety may be a promising approach for improving the quality of life of patients.

Exercise as adjunctive therapy for systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is a rare, chronic autoimmune inflammatory disease with a prevalence varying from 4.3 to 150 people in 100,000, or approximately five million people worldwide. Systemic manifestations frequently include internal organ involvement, a characteristic malar rash on the face, pain in joints and muscles, and profound fatigue. Exercise is purported to be beneficial for people with SLE. For this review, we focused on studies that examined all types of structured exercise as an adjunctive therapy in the management of SLE.

OBJECTIVES

To evaluate the benefits and harms of structured exercise as adjunctive therapy for adults with SLE compared with usual pharmacological care, usual pharmacological care plus placebo and usual pharmacological care plus non-pharmacological care.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 30 March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise as an adjunct to usual pharmacological treatment in SLE compared with placebo, usual pharmacological care alone and another non-pharmacological treatment. Major outcomes were fatigue, functional capacity, disease activity, quality of life, pain, serious adverse events, and withdrawals due to any reason, including any adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our major outcomes were 1. fatigue, 2. functional capacity, 3. disease activity, 4. quality of life, 5. pain, 6. serious adverse events, and 7. withdrawals due to any reason. Our minor outcomes were 8. responder rate, 9. aerobic fitness, 10. depression, and 11. anxiety. We used GRADE to assess certainty of evidence. The primary comparison was exercise compared with placebo.

MAIN RESULTS

We included 13 studies (540 participants) in this review. Studies compared exercise as an adjunct to usual pharmacological care (antimalarials, immunosuppressants, and oral glucocorticoids) with usual pharmacological care plus placebo (one study); usual pharmacological care (six studies); and another non-pharmacological treatment such as relaxation therapy (seven studies). Most studies had selection bias, and all studies had performance and detection bias. We downgraded the evidence for all comparisons because of a high risk of bias and imprecision. Exercise plus usual pharmacological care versus placebo plus usual pharmacological care Evidence from a single small study (17 participants) that compared whole body vibration exercise to whole body placebo vibration exercise (vibrations switched off) indicated that exercise may have little to no effect on fatigue, functional capacity, and pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). The study did not report disease activity, quality of life, and serious adverse events. The study measured fatigue using the self-reported Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue), scale 0 to 52; lower score means less fatigue. People who did not exercise rated their fatigue at 38 points and those who did exercise rated their fatigue at 33 points (mean difference (MD) 5 points lower, 95% confidence interval (CI) 13.29 lower to 3.29 higher). The study measured functional capacity using the self-reported 36-item Short Form health questionnaire (SF-36) Physical Function domain, scale 0 to 100; higher score means better function. People who did not exercise rated their functional capacity at 70 points and those who did exercise rated their functional capacity at 67.5 points (MD 2.5 points lower, 95% CI 23.78 lower to 18.78 higher). The study measured pain using the SF-36 Pain domain, scale 0 to 100; lower scores mean less pain. People who did not exercise rated their pain at 43 points and those who did exercise rated their pain at 34 points (MD 9 points lower, 95% CI 28.88 lower to 10.88 higher). More participants from the exercise group (3/11, 27%) withdrew from the study than the placebo group (1/10, 10%) (risk ratio (RR) 2.73, 95% CI 0.34 to 22.16). Exercise plus usual pharmacological care versus usual pharmacological care alone The addition of exercise to usual pharmacological care may have little to no effect on fatigue, functional capacity, and disease activity (low-certainty evidence). We are uncertain whether the addition of exercise improves pain (very low-certainty evidence), or results in fewer or more withdrawals (very low-certainty evidence). Serious adverse events and quality of life were not reported. Exercise plus usual care versus another non-pharmacological intervention such as receiving information about the disease or relaxation therapy Compared with education or relaxation therapy, exercise may reduce fatigue slightly (low-certainty evidence), may improve functional capacity (low-certainty evidence), probably results in little to no difference in disease activity (moderate-certainty evidence), and may result in little to no difference in pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). Quality of life and serious adverse events were not reported.

AUTHORS' CONCLUSIONS

Due to low- to very low-certainty evidence, we are not confident on the benefits of exercise on fatigue, functional capacity, disease activity, and pain, compared with placebo, usual care, or advice and relaxation therapy. Harms data were not well reported.

Effectiveness of Physical Activity Interventions on Return to Work After a Cancer Diagnosis: A Systematic Review and Meta-analysis

Purpose The aim of this study was to assess the effectiveness of physical activity (PA) interventions on return to work (RTW) in cancer survivors, compared to usual care, and to determine the dose of PA needed to improve this outcome. Methods A systematic review and meta-analysis were conducted according to PRISMA guidelines. Six electronic databases including PubMed, Embase, Web of Science, CENTRAL, PsycINFO, and Scopus were searched to identify studies, and completed by a search of grey literature and health organization websites. Two authors performed screening, selection, and data extraction independently. Study and intervention characteristics were extracted and summarized. Pooled risk ratio (RR) was estimated using a weight random-effects model with 95% confidence intervals (CIs). Results A total of 2655 records were identified, of which 8 intervention studies were included. The sample size of the included studies varied between 41 and 240, giving a total of 1087 participants aged between 18 and 75 years. Compared with usual care, PA interventions had a significant positive effect on RTW among cancer survivors with a pooled RR of 1.29 (95% CI 1.17, 1.42). We found that PA interventions (aerobic and resistance exercises) with an exercise dose between 7.6 METs.h/week and 15 METs.h/week, consisting in 50-60 min per session of moderate to vigorous physical exercise, twice a week seems relevant in improving RTW. Conclusions Our results showed, with moderate quality evidence that PA interventions are more effective than usual care in increasing the rate of RTW in cancer survivors. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Registration Number, CRD42020203614.

Community Reintegration After Rehabilitation for Hip Fracture: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effect of rehabilitation on the physical, social, and psychological dimensions of community reintegration after hip fracture.

DATA SOURCES

Electronic databases Embase, EMCare, MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health, and SPORTDiscus were searched from the earliest date available to second June 2021.

STUDY SELECTION

Searching identified 1844 potentially relevant articles. Twenty randomized controlled trials evaluating physical retraining, cognitive retraining, and model of care interventions on physical, social and psychological aspects of community reintegration for 3075 adults after hip fracture were included.

DATA EXTRACTION

Data were extracted using predetermined templates for participant characteristics, intervention type and setting, and outcomes related to community reintegration. Methodological quality was assessed using the Physiotherapy Evidence Database scale, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was applied to each meta-analysis.

DATA SYNTHESIS

Post intervention data were pooled to calculate risk ratios (RRs), mean differences, standardized mean differences, and 95% confidence intervals (CIs) using inverse variance methods and a random-effects model. Compared with usual care or no rehabilitation, there was moderate-quality evidence to suggest that physical retraining interventions improved outdoor mobility (RR, 1.45; 95% CI, 1.09-1.91; I2=0%) and moderate-quality evidence to suggest that physical retraining improved Nottingham Extended Activities of Daily Living Scale scores (physical and social reintegration) by a mean 3.5 units (95% CI, 0.99-6.01; I2=0%). Meta-analyses showed no significant effect for cognitive retraining and model of care interventions on any dimension of community reintegration.

CONCLUSIONS

Preliminary evidence suggests that physical rehabilitation after hip fracture improves physical and social aspects of community reintegration. The effect of psychological and home-based interventions on community reintegration is currently unclear. Further research is needed to determine the effect of rehabilitation on community reintegration, using interventions and measures that encompass all dimensions of community reintegration.

Interprofessional Collaboration and Diabetes Management in Primary Care: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes

The global spread of diabetes poses serious threats to public health requiring a patient-centered approach based both on interprofessional collaboration (IPC) given by the cooperation of several different health professionals, and patients’ perspective through the assessment of Patient-Reported Outcomes (PROs). The aim of the present study is to evaluate the impact of interprofessional collaboration interventions, for the management of type 2 diabetes in primary care settings, through PROs. A systematic review and meta-analysis was conducted querying the PubMed, Scopus and Embase databases. Out of the 1961 papers initially retrieved, 19 met the inclusion criteria. Interprofessional collaboration is significantly associated with an increase in both patient’s satisfaction (SMD 0.32 95% CI 0.05–0.59) and in the mental well-being component of the HRQoL (SMD 0.18; 95% CI 0.06–0.30), and there was also promising evidence supporting the association between an interprofessional approach and an increase in self-care and in generic and specific quality-of-life. No statistical differences were found, supporting the positive impact on IPC interventions on the physical component of the HRQoL, depression, emotional distress, and self-efficacy. In conclusion, the effect of IPC impacts positively on the few areas assessed by PROMs. Policymakers should promote the widespread adoption of a collaborative approach as well as to endorse an active engagement of patients across the whole process of care.

Experiences of Indigenous peoples in Canada with primary health care services: a qualitative systematic review protocol

OBJECTIVE

The objectives of this review are to aggregate and synthesize experiences of Indigenous peoples in Canada when receiving primary health care services; differentiate experiences from services provided in urban versus rural or remote settings; and identify recommendations to enhance quality of primary health care provision.

INTRODUCTION

Primary health care plays a crucial role in overall population health and health equity. In Canada, Indigenous peoples continue to face disproportionate health disparities. Survey and qualitative studies on the experiences of Indigenous populations with primary health care services reveal alarming findings of inadequate health care access, racial discrimination, negligence, and cultural insensitivities. However, these studies do not entirely assess the primary care and essential public health functions component. This protocol will be the first qualitative systematic review to thoroughly synthesize Indigenous peoples' overall primary health care experiences across all Canada, in both rural and urban settings.

INCLUSION CRITERIA

The population of interest is self-identified Indigenous peoples, who have first- and/or second-hand experience receiving primary health care services in Canada, regardless of their age, gender, or medical condition. Our focus is on patients' experiences in contexts where primary health care services are delivered in Canada. Only qualitative studies in English or French will be considered.

METHODS

MEDLINE, CINAHL, PubMed, PsycINFO, Embase, and Web of Science will be used as information sources in addition to Google Scholar, Bielefeld Academic Search Engine, ProQuest Dissertations and Theses, and other relevant organization websites. Two independent reviewers will perform the screening, critical appraisal, and data extraction of selected articles. Results will then be synthesized using the meta-aggregation approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020192353.

Safety and efficacy of a COVID-19 treatment with nebulized and/or intravenous neutral electrolyzed saline combined with usual medical care vs. usual medical care alone: A randomized, open-label, controlled trial

Coronavirus disease 2019 (COVID-19) is currently the major public health problem worldwide. Neutral electrolyzed saline solution that contains reactive chlorine and oxygen species may be an effective therapeutic. In the present study, the treatment efficacy of intravenous and/or nebulized neutral electrolyzed saline combined with usual medical care vs. usual medical care alone was evaluated in ambulatory patients with COVID-19. A prospective, 2-arm, parallel-group, randomized, open-label, multi-center, phase I-II clinical trial including 214 patients was performed. The following two outcomes were evaluated during the 20-day follow-up: i) The number of patients with disease progression; and ii) the patient acceptable symptom state. Serial severe acute respiratory syndrome coronavirus 2 naso/oro-pharyngeal detection by reverse transcription-quantitative (RT-q) PCR was performed in certain patients of the experimental group. Biochemical and hematologic parameters, as well as adverse effects, were also evaluated in the experimental group. The experimental treatment decreased the risk of hospitalization by 89% [adjusted relative risk (RR)=0.11, 95% confidence interval (CI): 0.03-0.37, P<0.001] and the risk of death by 96% (adjusted RR=0.04, 95% CI: 0.01-0.42, P=0.007) and also resulted in an 18-fold higher probability of achieving an acceptable symptom state on day 5 (adjusted RR=18.14, 95% CI: 7.29-45.09, P<0.001), compared with usual medical care alone. Overall, neutral electrolyzed saline solution was better than usual medical care alone. Of the patients analyzed, >50% were negative for the virus as detected by RT-qPCR in naso/oro-pharyngeal samples on day 4, with only a small number of positive patients on day 6. Clinical improvement correlated with a decrease in C-reactive protein, aberrant monocytes and increased lymphocytes and platelets. Cortisol and testosterone levels were also evaluated and a decrease in cortisol levels and an increase in the testosterone-cortisol ratio were observed on days 2 and 4. The experimental treatment produced no serious adverse effects. In conclusion, neutral electrolyzed saline solution markedly reduced the symptomatology and risk of progression in ambulatory patients with COVID-19. The present clinical trial was registered in the Cuban public registry of clinical trials (RPCEC) database (May 5, 2020; no. TX-COVID19: RPCEC00000309).

Occupational therapy addressing the ability to perform activities of daily living among persons living with chronic conditions: a randomised controlled pilot study of ABLE 2.0

BACKGROUND

The ABLE intervention was developed to enhance the ability to perform activities of daily living (ADL) tasks among persons living with chronic conditions. ABLE is a generic, home-based, individualised, 8-week occupational therapy intervention program, developed to be delivered in Danish municipalities. In a previous study, the feasibility of ABLE was evaluated in terms of content and delivery. In this pilot study, the remaining feasibility aspects of a randomised controlled trial including (i) trial procedures (recruitment and retention), (ii) randomisation, (iii) adherence to program, (iv) feasibility of additional outcome measurements, and (iv) access to information on usual occupational therapy were evaluated.

METHODS

The study was conducted in a Danish municipality, using a two-armed parallel randomised controlled design, planning a recruitment strategy including 20 persons living with one/more chronic conditions and experiencing problems performing ADL. The following progression criteria were used to determine if a future full-scale randomised controlled trial was feasible: (i) recruitment (50% met the eligibility criteria) and retention (80%), (ii) randomisation (80% accepted randomisation, procedure was executed as planned), (iii) adherence to program (100% followed the treatment protocol), (iv) outcome measurements (80% of the participants delivered relevantly and fully answered questionnaires), and (v) usual occupational therapy (extraction of needed information was successful).

RESULTS

Due to the COVID-19 pandemic, the study was truncated resulting in limited but sufficient data to answer most of the study questions. (i) Eighteen of 37 eligible persons (48.6%) were recruited; of those treated (n = 6), all remained (100%); (ii) 18 accepted randomisation (100%), and procedure was effective; (iii) ABLE was delivered with adherence (100%); (iv) 92.3-100% of the participants gave relevant and complete answers in two of three questionnaires; and (v) needed information on usual occupational therapy was extractable in seven of nine aspects.

CONCLUSIONS

Proceeding to full-scale trial is recommendable; however, a few adjustments on outcome measurements, inclusion criteria and extraction of information on usual occupational therapy are needed.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (Identifier: NCT04295837 ) on December 5th, 2019. Retrospectively registered.

Impact of interprofessional collaboration on chronic disease management: Findings from a systematic review of clinical trial and meta-analysis

Improvement of chronic disease management demands effective collaborative relationships between health and social-care which is achieved through teamwork. Interprofessional Education (IPE) and Interprofessional Collaboration (IPC) are recognized as essential for the delivery of effective and efficient healthcare. Although IPC and IPE are key components of primary care, evidence of studies evaluating how an IPE intervention prior to IPC improved chronic patient outcomes remains scarce. The aim of this study was to assess the impact of IPC interventions on the management of chronic patients compared to usual care. A systematic review and meta-analysis of Randomized Controlled Trials (RCTs) on IPC interventions on chronicity management and their impact on clinical and process outcomes was conducted. Of the 11,128 papers initially retrieved, 23 met the inclusion criteria. Meta-analyses results showed the reduction of systolic blood pressure (Mean Difference (MD) -3.70; 95 % CI -7.39, -0.01), glycosylated hemoglobin (MD -0.20; 95 % CI -0.47, -0.07), LDL cholesterol (MD -5.74; 95 % CI -9.34, -2.14), diastolic blood pressure (MD -1.95; 95 % CI -3.18, -0.72), days of hospitalization (MD -2.22; 95 % CI -4.30, -0.140). A number of positive findings for outcomes related to IPC were found reflecting an improvement of quality of care and an enhancement in the delivery of patient-centered and coordinated care. Moreover, the need for a purposeful systemic approach linking interprofessional education with interprofessional collaboration and patient health and wellbeing is necessary.

Palliative Care in Acute Heart Failure

Purpose of Review

Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

Recent Findings

The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research.

Summary

Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients’ preferences and values.

Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in hospital settings: A multi-method study using normalisation process theory

Purpose

To examine the use of Normalisation Process Theory (NPT) to establish if, and in what ways, the AMBER care bundle can be successfully normalised into acute hospital practice, and to identify necessary modifications to optimise its implementation.

Method

Multi-method process evaluation embedded within a mixed-method feasibility cluster randomised controlled trial in two district general hospitals in England. Data were collected using (i) focus groups with health professionals (HPs), (ii) semi-structured interviews with patients and/or carers, (iii) non-participant observations of multi-disciplinary team meetings and (iv) patient clinical note review. Thematic analysis and descriptive statistics, with interpretation guided by NPT components (coherence; cognitive participation; collective action; reflexive monitoring). Data triangulated across sources.

Results

Two focus groups (26 HPs), nine non-participant observations, 12 interviews (two patients, 10 relatives), 29 clinical note reviews were conducted. While coherence was evident, with HPs recognising the value of the AMBER care bundle, cognitive participation and collective action presented challenges. Specifically: (1) HPs were unable and unwilling to operationalise the concept of ‘risk of dying’ intervention eligibility criteria (2) integration relied on a ‘champion’ to drive participation and ensure sustainability; and (3) differing skills and confidence led to variable engagement with difficult conversations with patients and families about, for example, nearness to end of life. Opportunities for reflexive monitoring were not routinely embedded within the intervention. Reflections on the use of the AMBER care bundle from HPs and patients and families, including recommended modifications became evident through this NPT-driven analysis.

Conclusion

To be successfully normalised, new clinical practices, such as the AMBER care bundle, must be studied within the wider context in which they operate. NPT can be used to the aid identification of practical strategies to assist in normalisation of complex interventions where the focus of care is on clinical uncertainty in acute hospital settings.