The physician's experience of changing clinical practice: a struggle to unlearn

Micronutrient supplementation practices in relation to the World Health Organisation 2013 guidelines on management of severe acute malnutrition

In 2013, the World Health Organisation (WHO) updated the recommendations for micronutrient deficiency correction in hospitalised under-5 children with complicated severe acute malnutrition (SAM). This study aimed to describe the micronutrient deficiency correction practices in relation to WHO 2013 recommendations. Data from medical records of under-5 children admitted for SAM management at two hospitals in South Africa and three tertiary hospitals in Ghana were extracted. Micronutrient correction practices were compared to the WHO 2013 recommendations by considering the dosage, timing of micronutrient supplementation (vitamin A, iron and folic acid) and therapeutic feeds administered. In total, 723 medical records were included. Nearly half (48.3%) of the children received at least one of the studied micronutrients as a supplement. Vitamin A was supplemented in 27.4% of the children, while iron and folic acid were supplemented in 9.5% and 34.9%, respectively. Among the children who received vitamin A, 60.1% received the first dose on Day 1 of admission. Also, 46.4% of the iron-supplemented children received iron within the first week of admission. Vitamin A, iron and folic acid were administered within the dose range of 100,000-180,000 IU, 3.1-7.7 mg per kg per day, and 3-5 mg per day, respectively. Additionally, 71.7% of the children reportedly received therapeutic feeds that met WHO recommendations. The micronutrient deficiency correction practices regarding dose and timing differed from the 2013 WHO guidelines. Qualitative studies investigating the reasons for the disparities are recommended.

ECHO Autism Washington: Autism Diagnostic Evaluations in Primary Care

ECHO (Extensions for Community Healthcare Outcomes) Autism is a telementoring learning model to increase community capacity for autism-related health care. Seventy-seven pediatric providers (mostly primary care, seeing exclusively Medicaid patient populations) enrolled in 1 year of ECHO Autism Washington. Analysis of self-report surveys showed a significant increase in autism diagnoses made by ECHO providers after 1 year, F(1, 65) = 7.52, P = .008. Providers who attended more sessions reported making more diagnoses, F(2, 613.26), P = .045. Of note, autism diagnoses were not externally validated. The total number of reported barriers reduced, F(2, 61) = 13.5), P < .001, and confidence ratings increased F(2, 60) = 24.21, P < .001. The average number of diagnostic referrals from ECHO providers to the state's largest autism specialty clinic significantly reduced, t(43) = 4.23, P < .001, with significantly fewer diagnostic referrals made during and after ECHO training compared with a comparison group of 28 non-ECHO providers, t(58.77) = -3.36, P < .001. Overall, 1 year of ECHO Autism Washington participation led to significant changes in autism diagnostic practices.

Cutting back on low-value health care practices supports sustainable kidney care

July 2023 marked the hottest month on record, underscoring the urgent need for action on climate change. The imperative to reduce carbon emissions extends to all sectors, including health care, with it being responsible for 5.5% of global emissions. In decarbonizing health care, although much attention has focused on greening health care infrastructure and procurement, less attention has focused on reducing emissions through demand-side management. An important key element of this is reducing low-value care, given that ≈20% of global health care expenditure is considered low value. "Value" in health care, however, is subjective and dependent on how health outcomes are regarded. This review, therefore, examines the 3 main value perspectives specific to health care. Clinical effectiveness defines low-value care as interventions that offer little to no benefit or have a risk of harm exceeding benefits. Cost-effectiveness compares health outcomes versus costs compared with an alternative treatment. In this case, low-value care is care greater than a societal willingness to pay for an additional unit of health (quality-adjusted life year). Last, community perspectives emphasize the value of shared decision-making and patient-centered care. These values sit within broader societal values of ethics and equity. Any reduction in low-value care should, therefore, also consider patient autonomy, societal value perspectives and opportunity costs, and equity. Deimplementing entrenched low-value care practices without unnecessarily compromising ethics and equity will require tailored strategies, education, and transparency.

Preference for anti-phospholipase A2 receptor antibody assay in patients with suspected membranous nephropathy: a survey study on medical practice after publication of Japanese Guidelines for Nephrotic Syndrome 2020

BACKGROUND

International practice guidelines advocate for the use of anti-phospholipase A2 receptor (PLA2R) antibody testing to diagnose primary membranous nephropathy (pMN). This study aimed to clarify the current status of anti-PLA2R antibody testing in the diagnosis of pMN in Japan and to scrutinize the factors associated with the implementation of this antibody test.

METHODS

Utilizing a web-based questionnaire for nephrologists, responses were collected from 306 facilities and 427 nephrologists between November 2021 and December 2021. Preference for anti-PLA2R antibody testing was also investigated. Factors related to the experience of quantifying anti-PLA2R antibodies were estimated by generalized estimating equations using a robust analysis of variance with clusters of facilities of affiliation.

RESULTS

Of the 427 respondents, 140 (32.8%) had previous measurement experience at their current workplace and 165 (38.6%) had previous measurement experience overall. In pMN-suspected cases without contraindications to renal biopsy, 147 (34.4%) of the respondents opted to request anti-PLA2R antibody testing. The respondents' experience with anti-PLA2R antibody quantification at their current place of work was generally higher in university hospitals and increased with the annual number of kidney biopsies and the number of years since graduation.

CONCLUSION

The results of this study suggest that a significant proportion of nephrologists in Japan have no experience in performing anti-PLA2R antibody assays, and that the assays may be hampered by the limited capabilities of the current workplace and the financial burden on facilities and patients.

Development of a training program prototype to enhance implementation leadership competencies and behaviours of Chinese unit nurse managers: a qualitative descriptive study

BACKGROUND

Unit nurse managers hold essential positions that can facilitate implementation of evidence-based practice. Studies showed that nurse managers in China lacked competencies and behaviours necessary to lead evidence-based practice implementation. The aim of the current study was to develop a context-fit training program prototype to enhance leadership competencies and behaviours regarding evidence-based practice implementation of Chinese unit nurse managers.

METHOD

We used a descriptive qualitative study design and followed the integrated knowledge translation approach to co-develop the prototype in a tertiary hospital in Changsha, China. Seven nurse managers from the participated hospital and a researcher co-developed the prototype based on the Ottawa Model of Implementation Leadership (O-MILe). The development process encompassed four phases from November 2021 to March 2022 that involved group discussions (n = 4) and individual interviews (n = 21). All data were analysed by two independent researchers using the thematic analysis method.

RESULTS

Managers agreed that all O-MILe behaviours were important to evidence-based practice implementation, and only minor modifications were needed for clarification and adaptation. The actions managers identified that could operationalize the leadership behaviours were related to current clinical practices, evidence-based practice, nurses, patients, interprofessional staff members, incentives and resources, organization and external entities. Three types of general competencies related to evidence-based practice, professional nursing, and implementation leadership were identified. Multimodal activities such as lectures, experience sharing, group discussions, plan development and coaching were suggested to deliver the training program.

CONCLUSIONS

All O-MILe leadership behaviours were perceived as essential for unit nurse managers to lead EBP implementation in the hospital context in China. We identified the leadership actions and the competencies required for nursing managers to implement EBP in China. Further studies are required to evaluate the acceptability and impact of this prototype. Further studies with large sample sizes across various clinical settings are needed to facilitate the generalization of the findings and gain an in-depth understanding of the program.

Defining the transition from new to normal: a qualitative investigation of the clinical change process

Background

Understanding how and when a new evidence-based clinical intervention becomes standard practice is crucial to ensure that healthcare is delivered in alignment with the most up-to-date knowledge. However, rigorous methods are needed to determine when a new clinical practice becomes normalized to the standard of care. To address this gap, this study qualitatively explores how, when, and why a clinical practice change becomes normalized within healthcare organizations.

Methods

We used purposive sampling to recruit clinical leaders who worked in implementation science across diverse health contexts. Enrolled participants completed semi-structured interviews. Qualitative data analysis was guided by a modified version of the Normalization Process Theory (NPT) framework to identify salient themes. Identified normalization strategies were mapped to the Expert Recommendations for Implementation Change (ERIC) project.

Results

A total of 17 individuals were interviewed. Participants described four key signals for identifying when a novel clinical practice becomes the new normal: 1) integration into existing workflows; 2) scaling across the entire organizational unit; 3) staff buy-in and ownership; and 4) sustainment without ongoing monitoring. Participants identified salient strategies to normalize new clinical interventions: 1) taking a patient approach; 2) gaining staff buy-in and ownership; and 3) conducting ongoing measurement of progress towards normalization.

Conclusions

The results offer valuable insight into the indicators that signify when a novel clinical practice becomes normalized, and the strategies employed to facilitate this transition. These findings can inform future research to develop instruments that implementation leaders can use to systematically measure the clinical change process.

Access to Urgent Care Practices Improves Understanding and Management of Endemic Coccidioidomycosis: Maricopa County, Arizona, 2018-2023

BACKGROUND

Coccidioidomycosis within endemic regions is often undiagnosed because appropriate testing is not performed. A dashboard was developed to provide information about the prevalence of coccidioidomycosis throughout the year.

METHODS

Banner Urgent Care Service has many clinics within Maricopa County, Arizona, a highly endemic region for coccidioidomycosis. All clinic visits and subset analyses for patients with International Classification of Diseases, Tenth Revision codes for pneumonia (J18.*) or erythema nodosum (L52) during 2018-2024 were included. Tabulated were daily frequencies of visits, pneumonia and erythema nodosum coding, coccidioidal testing, and test results. Banner Urgent Care Services' counts of monthly coccidioidomycosis diagnoses were compared with those of confirmed coccidioidomycosis cases reported to Maricopa County Department of Public Health.

RESULTS

Monthly frequencies of urgent care coccidioidomycosis diagnoses strongly correlated with public health coccidioidomycosis case counts (r = 0.86). Testing frequency for coccidioidomycosis correlated with overall pneumonia frequency (r = 0.52). The proportion of pneumonia due to coccidioidomycosis varied between <5% and >45% within and between years. Coccidioidomycosis was a common cause of erythema nodosum (65%; 95% confidence interval, 45%-67%) and independent of pneumonia. Over half of Banner Urgent Care Services' coccidioidomycosis diagnoses were coded for neither pneumonia nor erythema nodosum.

CONCLUSION

Data provided by the coccidioidomycosis dashboard can assist urgent care practitioners in knowing when coccidioidomycosis is prevalent in the community. Patients with exposure to endemic coccidioidomycosis who develop erythema nodosum or pneumonia should routinely be tested for coccidioidomycosis. Data from private health care organizations can augment surveillance of diseases important to public health.

Factors Associated with Acute Telemental Health Consultations in Older Veterans

Introduction

The United States Veterans Health Administration is a leader in the use of telemental health (TMH) to enhance access to mental healthcare amidst a nationwide shortage of mental health professionals. The Tennessee Valley Veterans Affairs (VA) Health System piloted TMH in its emergency department (ED) and urgent care clinic (UCC) in 2019, with full 24/7 availability beginning March 1, 2020. Following implementation, preliminary data demonstrated that veterans ≥65 years old were less likely to receive TMH than younger patients. We sought to examine factors associated with older veterans receiving TMH consultations in acute, unscheduled, outpatient settings to identify limitations in the current process.

Methods

This was a retrospective cohort study conducted within the Tennessee Valley VA Health System. We included veterans ≥55 years who received a mental health consultation in the ED or UCC from April 1, 2020-September 30, 2022. Telemental health was administered by a mental health clinician (attending physician, resident physician, nurse practitioner, or physician assistant) via iPad, whereas in-person evaluations were performed in the ED. We examined the influence of patient demographics, visit timing, chief complaint, and psychiatric history on TMH, using multivariable logistic regression.

Results

Of the 254 patients included in this analysis, 177 (69.7%) received TMH. Veterans with high-risk chief complaints (suicidal ideation, homicidal ideation, or agitation) were less likely to receive TMH consultation (adjusted odds ratio [AOR]: 0.47, 95% confidence interval [CI] 0.24-0.95). Compared to attending physicians, nurse practitioners and physician assistants were associated with increased TMH use (AOR 4.81, 95% CI 2.04-11.36), whereas consultation by resident physicians was associated with decreased TMH use (AOR 0.04, 95% CI 0.00-0.59). The UCC used TMH for all but one encounter. Patient characteristics including their visit timing, gender, additional medical complaints, comorbidity burden, and number of psychoactive medications did not influence use of TMH.

Conclusion

High-risk chief complaints, location, and type of mental health clinician may be key determinants of telemental health use in older adults. This may help expand mental healthcare access to areas with a shortage of mental health professionals and prevent potentially avoidable transfers in low-acuity situations. Further studies and interventions may optimize TMH for older patients to ensure safe, equitable mental health care.

Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program

OBJECTIVE

Primary care practitioners are crucial to engaging people in Australia's national cervical screening program. From July 2022, practitioners have been able to offer all screen-eligible people the choice to collect their own self-collected sample; an option introduced to increase equity. This study explored how practitioners are intending to incorporate universal access to self-collection into their clinical care.

METHODS

Semi-structed interviews with 27 general practitioners, nurses, and practice managers from 10 practices in Victoria, Australia conducted between May and August 2022. Interviews were deductively coded, informed by the Consolidated Framework for Implementation Research. The Diffusion of Innovations theory was used to categorise intention to provide self-collection.

RESULTS

Participants were supportive of universal access to self-collection, citing benefits for screen-eligible people and that it overcame the limited adaptability of the previous policy. Most participants' practices (n = 7, 70%) had implemented or had plans to offer the option for self-collection to all. Participants deliberating whether to provide universal access to self-collection held concerns about the correct performance of the self-test and the perceived loss of opportunity to perform a pelvic examination. Limited time to change practice-level processes and competing demands within consultations were anticipated as implementation barriers.

CONCLUSIONS

The extent to which self-collection can promote equity within the program will be limited without wide-spread adoption by practitioners. Communication and education that addresses concerns of practitioners, along with targeted implementation support, will be critical to ensuring that self-collection can increase participation and Australia's progression towards elimination of cervical cancer.

Application of the Stanford Biodesign Framework in Healthcare Innovation Training and Commercialization of Market Appropriate Products: A Scoping Review

The Stanford Biodesign needs-centric framework can guide healthcare innovators to successfully adopt the 'Identify, Invent and Implement' framework and develop new healthcare innovations products to address patients' needs. This scoping review explored the application of the Stanford Biodesign framework for healthcare innovation training and the development of novel healthcare innovative products. Seven electronic databases were searched from their respective inception dates till April 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations, and Theses Global. This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews and was guided by the Arksey and O'Malley's scoping review framework. Findings were analyzed using Braun and Clarke's thematic analysis framework. Three themes and eight subthemes were identified from the 26 included articles. The main themes are: (1) Making a mark on healthcare innovation, (2) Secrets behind success, and (3) The next steps. The Stanford Biodesign framework guided healthcare innovation teams to develop new medical products and achieve better patient health outcomes through the induction of training programs and the development of novel products. Training programs adopting the Stanford Biodesign approach were found to be successful in improving trainees' entrepreneurship, innovation, and leadership skills and should continue to be promoted. To aid innovators in commercializing their newly developed medical products, additional support such as securing funds for early start-up companies, involving clinicians and users in product testing and validation, and establishing new guidelines and protocols for the new healthcare products would be needed.

Determining acceptance and perceptions of chemotherapy dose banding in an ambulatory cancer centre

INTRODUCTION

Despite the advantages of dose banding (DB) and numerous plans to adopt this practice, uptake of DB is still poor. As opinions of healthcare professionals were deemed essential in DB's acceptance, this study surveyed key stakeholders to determine the acceptance, facilitators, and barriers of DB in chemotherapy to improve its implementation.

METHODS

A cross-sectional study at the National Cancer Centre Singapore, involving physicians, nurses, and pharmacy staff, was conducted in February 2022. The Theory of Planned Behaviour was adapted to design a survey questionnaire to obtain the acceptance, facilitators, and barriers of DB. Additional questions on maximum acceptable dose variance and essential criteria for selecting drugs for DB were included.

RESULTS

A total of 93 participants responded, with a mean 9.75  ±  7.37 years of clinical experience. Less than half have heard of DB while few had prior experience. Drug cost was the top selection criteria for DB, followed by toxicity, therapeutic index, frequency of use and drug wastage. Acceptance rate of DB was 41.9%, with majority agreeing to use DB in various drugs but to determine patient suitability before usage. Being greatly affected by subjective norms, having a positive outlook for DB's impacts, and no effect on toxicity significantly influenced acceptance.

CONCLUSION

Prior to implementing DB at the institutional level, educational training addressing concerns over toxicity, and providing technological support can help improve acceptance. Future studies can involve patients' perspectives and more institutions for greater diversity in opinions.

Application of a user experience design approach for an EHR-based clinical decision support system

Objective

We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool.

Materials and methods

We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management.

Results

The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake.

Discussion

Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference.

Conclusion

A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

Practice patterns of rituximab for primary membranous nephropathy 2021 in Japan: a web-based survey of board-certified nephrologists

BACKGROUND

Although rituximab (RTX) is recommended by kidney disease improving global outcomes as one of the standard therapies for primary membranous nephropathy (pMN), given the constraint of insurance coverage, it is not clear how the drug is used in Japan.

METHODS

This cross-sectional study was conducted via a web-based survey between November and December 2021. The participants were certified nephrologists and recruited through convenience sampling. Experience with RTX for pMN was compared to experience with RTX for minimal change nephrotic syndrome (MCNS). Reasons for withholding RTX for pMN, even when it is indicated, were also investigated. Furthermore, the proportion difference in RTX experience was analyzed.

RESULTS

Responses from 380 nephrologists across 278 facilities were analyzed. RTX was used for pMN by 83 (21.8%), which was less than the 181 (47.6%) who had used RTX for MCNS (ratio of proportions: 0.46). RTX use for pMN was more frequent in facilities performing 41-80 and 81 or more kidney biopsies annually (vs. none) and by physicians with experience in anti-PLA2R antibody measurement. RTX administration for pMN was covered by insurance for 56 (67.5%), was facility-paid for 10 (12.0%), and was copaid by patients for 6 (7.2%). The most common reason for withholding RTX for pMN was difficulty in ensuring financing (146, 79.3%).

CONCLUSIONS

RTX use for pMN is less common than for MCNS but not infrequent. Treatment with RTX was more frequent in biopsy-intensive facilities, and it was fully paid by the facility or patient in one-fifth of cases.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review

Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.

Should we screen aging physicians for cognitive decline?

OBJECTIVES

To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians.

METHODS

Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized.

RESULTS

Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties.

CONCLUSION

Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.

The methodology of the Agile Nudge University

Introduction

The Agile Nudge University is a National Institute on Aging-funded initiative to engineer a diverse, interdisciplinary network of scientists trained in Agile processes.

Methods

Members of the network are trained and mentored in rapid, iterative, and adaptive problem-solving techniques to develop, implement, and disseminate evidence-based nudges capable of addressing health disparities and improving the care of people living with Alzheimer's disease and other related dementias (ADRD).

Results

Each Agile Nudge University cohort completes a year-long online program, biweekly coaching and mentoring sessions, monthly group-based problem-solving sessions, and receives access to a five-day Bootcamp and the Agile Nudge Resource Library.

Discussion

The Agile Nudge University is evaluated through participant feedback, competency surveys, and tracking of the funding, research awards, and promotions of participating scholars. The Agile Nudge University is compounding national innovation efforts in overcoming the gaps in the ADRD discovery-to-delivery translational cycle.

Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system

Introduction

Health systems have many incentives to screen patients for health-related social needs (HRSNs) due to growing evidence that social determinants of health impact outcomes and a new regulatory context that requires health equity measures. This study describes the experience of one large urban health system in scaling HRSN screening by implementing improvement strategies over five years, from 2018 to 2023.

Methods

In 2018, the health system adapted a 10-item HRSN screening tool from a widely used, validated instrument. Implementation strategies aimed to foster screening were retrospectively reviewed and categorized according to the Expert Recommendations for Implementing Change (ERIC) study. Statistical process control methods were utilized to determine whether implementation strategies contributed to improvements in HRSN screening activities.

Results

There were 280,757 HRSN screens administered across 311 clinical teams in the health system between April 2018 and March 2023. Implementation strategies linked to increased screening included integrating screening within an online patient portal (ERIC strategy: involve patients/consumers and family members), expansion to discrete clinical teams (ERIC strategy: change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical data to providers), and deploying Community Health Workers to address HRSNs (ERIC strategy: create new clinical teams).

Conclusion

Implementation strategies designed to promote efficiency, foster universal screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening demonstrate the cumulative effects of implementation strategies and the health system's commitment toward universal screening.

Awareness and knowledge of female genital schistosomiasis in a population with high endemicity: a cross-sectional study in Madagascar

Introduction

Female genital schistosomiasis (FGS) is a neglected disease with long-term physical and psychosocial consequences, affecting approximately 50 million women worldwide and generally representing an unmet medical need on a global scale. FGS is the chronic manifestation of a persistent infection with Schistosoma haematobium. FGS services are not routinely offered in endemic settings with a small percentage of women at risk receiving adequate care. Madagascar has over 60% prevalence of FGS and no guidelines for the management of the disease. This study aimed to determine FGS knowledge among women and health care workers (HCWs) in a highly endemic area of Madagascar.

Methods

A convenience sampling strategy was used for this cross-sectional study. Descriptive statistics including proportions and 95% confidence intervals (CI) were calculated, reporting socio-demographic characteristics of the population. Knowledge sources were evaluated descriptively. Binary Poisson regression with robust standard errors was performed; crude (CPR) and adjusted prevalence ratio (APR) with 95% CIs were calculated.

Results

A total of 783 participants were included in the study. Among women, 11.3% (n = 78) were aware of FGS while among the HCWs 53.8% (n = 50) were aware of FGS. The highest level of knowledge was observed among women in an urban setting [24%, (n = 31)] and among those with a university education/vocational training [23% (n = 13)]. A lower APR of FGS knowledge was observed in peri-urban [APR 0.25 (95% CI: 0.15; 0.45)] and rural [APR 0.37 (95% CI 0.22; 0.63)] settings in comparison to the urban setting. Most HCWs reported other HCWs [40% (n = 20)] while women mainly reported their family [32% (n = 25)] as being their main source of information in the 6 months prior to the survey.

Discussion and conclusions

Our study shows limited awareness and knowledge of FGS among population groups in the highly endemic Boeny region of Madagascar. With this study we contribute to identifying an important health gap in Madagascar, which relates to a disease that can silently affect millions of women worldwide. In alignment with the targets of the NTD roadmap, addressing schistosomiasis requires a paradigm shift for its control and management including a greater focus on chronic forms of the disease.

The clinical application of beta-lactam antibiotic therapeutic drug monitoring in the critical care setting

Critically ill patients have increased variability in beta-lactam antibiotic (beta-lactam) exposure due to alterations in their volume of distribution and elimination. Therapeutic drug monitoring (TDM) of beta-lactams, as a dose optimization and individualization tool, has been recommended to overcome this variability in exposure. Despite its potential benefit, only a few centres worldwide perform beta-lactam TDM. An important reason for the low uptake is that the evidence for clinical benefits of beta-lactam TDM is not well established. TDM also requires the availability of specific infrastructure, knowledge and expertise. Observational studies and systematic reviews have demonstrated that TDM leads to an improvement in achieving target concentrations, a reduction in potentially toxic concentrations and improvement of clinical and microbiological outcomes. However, a small number of randomized controlled trials have not shown a mortality benefit. Opportunities for improved study design are apparent, as existing studies are limited by their inclusion of heterogeneous patient populations, including patients that may not even have infection, small sample size, variability in the types of beta-lactams included, infections caused by highly susceptible bacteria, and varied sampling, analytical and dosing algorithm methods. Here we review the fundamentals of beta-lactam TDM in critically ill patients, the existing clinical evidence and the practical aspects involved in beta-lactam TDM implementation.

Impact of model-informed precision dosing on achievement of vancomycin exposure targets in pediatric patients with cystic fibrosis

BACKGROUND

Vancomycin is commonly used to treat acute pulmonary exacerbations in pediatric patients with cystic fibrosis (CF) and a history of methicillin-resistant Staphylococcus aureus. Optimizing vancomycin exposure during therapy is essential and area under-the-curve (AUC)-guided dosing is now recommended. Model-informed precision dosing (MIPD) utilizing Bayesian forecasting is a powerful approach that can support AUC-guided dose individualization. The objective of the current study was to examine the impact of implementing an AUC-guided dose individualization approach supported via a MIPD clinical decision support (CDS) tool on vancomycin exposure, target attainment rate, and safety in pediatric patients with CF treated with vancomycin during clinical care.

METHODS

A retrospective chart review was performed in patients with CF at a single children's hospital comparing pre- and post-implementation of a MIPD approach for vancomycin supported by a cloud-based, CDS tool integrated into the electronic health record (EHR). In the pre-MIPD period, vancomycin starting doses of 60 mg/kg/day (<13 years) or 45 mg/kg/day (≥13 years) were used. Dose adjustment was guided by therapeutic drug monitoring (TDM) with a target trough 10-20 mg/L. In the post-MIPD period, starting dose and dose adjustment were based on the MIPD CDS tool predictions with a target 24 h AUC (AUC24 ) 400-600 mg*h/L. Exposure and target achievement rates were retrospectively calculated and compared. Rates of acute kidney injury (AKI) were also compared.

RESULTS

Overall, 23 patient courses were included in the pre-MIPD period and 21 patient courses in the post-MIPD period. In the post-MIPD period, an individualized MIPD starting dose resulted in 71% of patients achieving target AUC24 compared to 39% in the pre-MIPD period (p < 0.05). After the first TDM and dose adjustment, target AUC24 achievement was also higher post-MIPD versus pre-MIPD (86% vs. 57%; p < 0.05). AKI rates were low and similar between periods (pre-MIPD 8.7% vs. post-MIPD 9.5%; p = 0.9).

CONCLUSION

An MIPD approach implemented within a cloud-based, EHR-integrated CDS tool safely supported vancomycin AUC-guided dosing and resulted in high rates of target achievement.

Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess

BACKGROUND

Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as clinical management tools (CMT), to reduce high-risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED).

METHODS

We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates.

RESULTS

In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference +1.0%, 95% CI -4.5% to 6.5%). Mean number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). Back pain visits receiving CT (13.7% vs. 21.1%, difference +7.3%, 95% CI 6.1% to 8.6%) and MRI (2.9% vs. 4.4%, difference +1.4%, 95% CI 1.0% to 1.9%) increased. Spine X-rays decreased (22.6% vs. 20.5%, difference 2.1%, 95% CI -4.3% to 0.1%). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference +1.6%, 95% CI 1.3% to 1.9%).

CONCLUSIONS

Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.

Clinical practice guideline recommendations for diagnosis and management of anxiety and depression in hospitalized adults with delirium: a systematic review

BACKGROUND

Delirium commonly occurs in hospitalized adults. Psychiatric disorders such as anxiety, depression, and post-traumatic stress disorder (PTSD) can co-occur with delirium, and can be recognized and managed by clinicians using recommendations found in methodological guiding statements called Clinical Practice Guidelines (CPGs). The specific aims of this review were to: [1] synthesize CPG recommendations for the diagnosis and management of anxiety, depression, and PTSD in adults with delirium in acute care; and [2] identify recent published literature in addition to those identified and reported in a 2017 review on delirium CPG recommendations and quality.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, and 21 sites on the Canadian Agency for Drugs and Technologies listed in the Health Grey Matters Lite tool were searched from inception to February 12, 2021. Selected CPGs focused on delirium in acute care, were endorsed by an international scientific society or governmental organization, and contained at least one recommendation for the diagnosis or management of delirium. Two reviewers independently extracted data in duplicate and independently assessed CPG quality using the AGREE-II tool. Narrative synthesis of CPG recommendations was conducted.

RESULTS

Title and abstract screening was completed on 7611 records. Full-text review was performed on 197 CPGs. The final review included 27 CPGs of which 7 (26%) provided recommendations for anxiety (4/7, 57%), depression (5/7, 71%), and PTSD (1/7, 14%) in delirium. Twenty CPGs provided recommendations for delirium only (e.g., assess patient regularly, avoid use of benzodiazepines). Recommendations for the diagnosis of psychiatric disorders with delirium included using evidence-based diagnostic criteria and standardized screening tools. Recommendations for the management of psychiatric disorders with delirium included pharmacological (e.g., anxiolytics, antidepressants) and non-pharmacological interventions (e.g., promoting patient orientation using clocks). Guideline quality varied: the lowest was Applicability (mean = 36%); the highest Clarity of Presentation (mean = 76%).

CONCLUSIONS

There are few available evidence-based CPGs to facilitate appropriate diagnosis and management of anxiety, depression, and PTSD in patients with delirium in acute care. Future guideline developers should incorporate evidence-based recommendations on the diagnosis and management of these psychiatric disorders in delirium.

SYSTEMATIC REVIEW REGISTRATION

Registration number: PROSPERO (CRD42021237056).

Outcome of Water Exchange and Air Insufflation Colonoscopy Performed by Supervised Trainee and Their Assessment of the Training Experience

GOALS

The hypotheses that supervised trainees would provide a more favorable assessment of the learning experience and could achieve superior results with water exchange (WE) compared with air insufflation were tested.

BACKGROUND

WE decreased pain, increased cecal intubation rate (CIR), and polyp detection rate (PDR).

STUDY

In a prospective pilot observational study, the trainees were taught WE in unsedated and WE and air insufflation in alternating order in sedated veterans. Trainee scores and procedural outcomes were tracked.

RESULTS

83 air insufflation and 119 WE cases were included. Trainee evaluations of the respective methods were scored based on a 5-point scale [1 (strongly agree) to 5 (strongly disagree, with lower scores being more favorable]. Evaluation scores [mean (SD)] were as follows: my colonoscopy experience was better than expected: WE 2.02 (1.00) versus air insufflation 2.43 (1.19), P =0.0087; I was confident with my technical skills using this method: WE 2.76 (0.91) versus air insufflation 2.85 (0.87), P =0.4822. Insertion time was 40 (21) min for WE and 30 (20) min for air insufflation ( P =0.0008). CIR were 95% (WE, unsedated); 99% (WE, overall), and 89% (air insufflation, overall). WE showed significantly higher CIR (99% vs. 89%, P =0.0031) and PDR (54% vs. 32%, P =0.0447).

CONCLUSIONS

The long air insufflation insertion time indicated the trainees were inexperienced. The significantly longer WE insertion time confirmed that learning WE required extra time. This pilot study revealed that supervised trainees reported more favorable learning experience with WE and equivalent confidence in technical skills scores. They completed both unsedated and sedated colonoscopy in over 89% of cases achieved significantly higher CIR and PDR with WE than air insufflation. It appeared that trainee education in WE might be an acceptable alternative to augment air insufflation to meet the challenges of training posed by traditional air insufflation colonoscopy.

Childhood fever and medical students: A multicentre, educational intervention

AIM

Misconceptions and non-evidence-based practices toward childhood fever are reported worldwide. Medical students might be ideal candidates to introduce long-lasting changes in clinical practice. However, no study has gauged the effectiveness of an educational intervention to improve fever management in this population. We conducted an educational, interventional study on childhood fever among final-year medical students.

METHODS

We conducted a prospective, multicentre interventional study employing a pre/post-test design. Participants from three Italian Universities filled in a questionnaire just before the intervention (T0), immediately after (T1) and 6 months later (T2) in 2022. The intervention was a two-hour lecture focused on the pathophysiology of fever, recommendations for its treatment and risks associated with improper management.

RESULTS

188 final-year medical students (median age of 26 years, 67% females) were enrolled. Relevant improvements in the criterion for treating fever and conceptions about the beneficial effects of fever were observed at T1 and T2. Similar data were found for the reduction of physical methods advice to decrease body temperature and concerns for brain damage from fever.

CONCLUSION

This study shows for the first time that an educational intervention is effective in changing students' conceptions and attitudes toward fever both in the short and medium term.

FeBRILe3: Safety Evaluation of Febrile Infant Guidelines Through Prospective Bayesian Monitoring

OBJECTIVES

Despite evidence supporting earlier discharge of well-appearing febrile infants at low risk of serious bacterial infection (SBI), admissions for ≥48 hours remain common. Prospective safety monitoring may support broader guideline implementation.

METHODS

A sequential Bayesian safety monitoring framework was used to evaluate a new hospital guideline recommending early discharge of low-risk infants. Hospital readmissions within 7 days of discharge were regularly assessed against safety thresholds, derived from historic rates and expert opinion, and specified a priori (8 per 100 infants). Infants aged under 3 months admitted to 2 Western Australian metropolitan hospitals for management of fever without source were enrolled (August 2019-December 2021), to a prespecified maximum 500 enrolments.

RESULTS

Readmission rates remained below the prespecified threshold at all scheduled analyses. Median corrected age was 34 days, and 14% met low-risk criteria (n = 71). SBI was diagnosed in 159 infants (32%), including urinary tract infection (n = 140) and bacteraemia (n = 18). Discharge occurred before 48 hours for 192 infants (38%), including 52% deemed low-risk. At study completion, 1 of 37 low-risk infants discharged before 48 hours had been readmitted (3%), for issues unrelated to SBI diagnosis. In total, 20 readmissions were identified (4 per 100 infants; 95% credible interval 3, 6), with >0.99 posterior probability of being below the prespecified noninferiority threshold, indicating acceptable safety.

CONCLUSIONS

A Bayesian monitoring approach supported safe early discharge for many infants, without increased risk of readmission. This framework may be used to embed safety evaluations within future guideline implementation programs to further reduce low-value care.

Integrating MOUD and Primary Care: Outcomes of a Multicenter Learning Collaborative

BACKGROUND AND OBJECTIVES

Opioid use and overdose remain a central and worsening public health emergency in the United States and abroad. Efforts to expand treatment have struggled to match the rising incidence of opioid use disorder (OUD), and treating patients in primary care settings represents one of the most promising opportunities to meet this need. Learning collaboratives (LCs) are one evidence-based strategy to improve implementation of medication treatment for opioid use disorder (MOUD) in primary care.

METHODS

We developed and studied a multidisciplinary MOUD learning collaborative involving six underserved primary care clinics. We used a mixed-methods approach to assess needs, develop curriculum, and evaluate outcomes from these clinics.

RESULTS

We recruited six clinics to participate in the collaborative. Half had an established MOUD program. Approximately 80% of participants achieved their organizational quality improvement goals for the collaborative. After the collaborative, participants also reported a significant increase in their perceived competence to implement/improve a MOUD program (pre-LC competence=2.80, post-LC competence=6.33/10, P=.02). The most consistent barrier we identified was stigma around OUD and its effects on patients' ability to access services and staff/provider ability to provide services. The most frequent enablers of program success were trainee interest, organizational leadership support, and a dedicated MOUD care team.

CONCLUSIONS

Organizations used clinical and systems improvement knowledge to enhance their existing programs or to take steps to create new programs. All participants identified the need for additional staff/clinician training, especially to overcome stigma around OUD. The outcomes demonstrated the crucial importance of long-term organizational support for program success.

Framework for Implementing Individualised Dosing of Anti-Cancer Drugs in Routine Care: Overcoming the Logistical Challenges

Precision medicine in oncology involves identifying the 'right drug', at the 'right dose', for the right person. Currently, many orally administered anti-cancer drugs, particularly kinase inhibitors (KIs), are prescribed at a standard fixed dose. Identifying the right dose remains one of the biggest challenges to optimal patient care. Recently the Precision Dosing Group established the Accurate Dosing of Anti-cancer Patient-centred Therapies (ADAPT) Program to address individualised dosing; thus, use existing anti-cancer drugs more safely and efficiently. In this paper, we outline our framework, based on the Medical Research Council (MRC) framework, with a simple 6-step process and strategies which have led to the successful implementation of the ADAPT program in South Australia. Implementation strategies in our 6-step process involve: (1) Evaluate the evidence and identify the cancer drugs: Literature review, shadowing other experts, establishing academic partnerships, adaptability/flexibility; (2) Establishment of analytical equipment for drug assays for clinical purposes: assessment for readiness, accreditation, feasibility, obtaining formal commitments, quality assurance to all stakeholders; (3) Clinical preparation and education: educational material, conducted educational meetings, involve opinion leaders, use of mass media, promote network weaving, conduct ongoing training; (4) Blood collection, sample preparation and analyses: goods received procedures, critical control points (transport time); (5) Interpret and release results with recommendations: facilitate the relay of clinical data to providers; (6) Clinical application: providing ongoing consultation, identify early adopters, identify, and prepare champions. These strategies were selected from the 73 implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) study. The ADAPT program currently provides routine plasma concentrations for patients on several orally administered drugs in South Australia and is currently in its evaluation phase soon to be published. Our newly established framework could provide great potential and opportunities to advance individualised dosing of oral anti-cancer drugs in routine clinical care.

Defining re-implementation

BACKGROUND

The first attempt to implement a new tool or practice does not always lead to the desired outcome. Re-implementation, which we define as the systematic process of reintroducing an intervention in the same environment, often with some degree of modification, offers another chance at implementation with the opportunity to address failures, modify, and ultimately achieve the desired outcomes. This article proposes a definition and taxonomy for re-implementation informed by case examples in the literature.

MAIN BODY

We conducted a scoping review of the literature for cases that describe re-implementation in concept or practice. We used an iterative process to identify our search terms, pilot testing synonyms or phrases related to re-implementation. We searched PubMed and CINAHL, including articles that described implementing an intervention in the same environment where it had already been implemented. We excluded articles that were policy-focused or described incremental changes as part of a rapid learning cycle, efforts to spread, or a stalled implementation. We assessed for commonalities among cases and conducted a thematic analysis on the circumstance in which re-implementation occurred. A total of 15 articles representing 11 distinct cases met our inclusion criteria. We identified three types of circumstances where re-implementation occurs: (1) failed implementation, where the intervention is appropriate, but the implementation process is ineffective, failing to result in the intended changes; (2) flawed intervention, where modifications to the intervention itself are required either because the tool or process is ineffective or requires tailoring to the needs and/or context of the setting where it is used; and (3) unsustained intervention, where the initially successful implementation of an intervention fails to be sustained. These three circumstances often co-exist; however, there are unique considerations and strategies for each type that can be applied to re-implementation.

CONCLUSIONS

Re-implementation occurs in implementation practice but has not been consistently labeled or described in the literature. Defining and describing re-implementation offers a framework for implementation practitioners embarking on a re-implementation effort and a starting point for further research to bridge the gap between practice and science into this unexplored part of implementation.

AutoPrognosis 2.0: Democratizing diagnostic and prognostic modeling in healthcare with automated machine learning

Diagnostic and prognostic models are increasingly important in medicine and inform many clinical decisions. Recently, machine learning approaches have shown improvement over conventional modeling techniques by better capturing complex interactions between patient covariates in a data-driven manner. However, the use of machine learning introduces technical and practical challenges that have thus far restricted widespread adoption of such techniques in clinical settings. To address these challenges and empower healthcare professionals, we present an open-source machine learning framework, AutoPrognosis 2.0, to facilitate the development of diagnostic and prognostic models. AutoPrognosis leverages state-of-the-art advances in automated machine learning to develop optimized machine learning pipelines, incorporates model explainability tools, and enables deployment of clinical demonstrators, without requiring significant technical expertise. To demonstrate AutoPrognosis 2.0, we provide an illustrative application where we construct a prognostic risk score for diabetes using the UK Biobank, a prospective study of 502,467 individuals. The models produced by our automated framework achieve greater discrimination for diabetes than expert clinical risk scores. We have implemented our risk score as a web-based decision support tool, which can be publicly accessed by patients and clinicians. By open-sourcing our framework as a tool for the community, we aim to provide clinicians and other medical practitioners with an accessible resource to develop new risk scores, personalized diagnostics, and prognostics using machine learning techniques. Software: https://github.com/vanderschaarlab/AutoPrognosis.

Mixed-methods feasibility study to inform a randomised controlled trial of proton pump inhibitors to reduce strictures following neonatal surgery for oesophageal atresia

OBJECTIVES

This mixed-methods feasibility study aimed to explore parents' and medical practitioners' views on the acceptability and design of a clinical trial to determine whether routine prophylactic proton pump inhibitors (PPI) reduce the incidence of anastomotic stricture in infants with oesophageal atresia (OA).

DESIGN

Semi-structured interviews with UK parents of an infant with OA and an online survey, telephone interviews and focus groups with clinicians. Data were analysed using reflexive thematic analysis and descriptive statistics.

PARTICIPANTS AND SETTING

We interviewed 18 parents of infants with OA. Fifty-one clinicians (49 surgeons, 2 neonatologists) from 20/25 (80%) units involved in OA repair completed an online survey and 10 took part in 1 of 2 focus groups. Interviews were conducted with two clinicians whose survey responses indicated they had concerns about the trial.

OUTCOME MEASURES

Parents and clinicians ranked the same top four outcomes ('Severity of anastomotic stricture', 'Incidence of anastomotic stricture', 'Need for treatment of reflux' and 'Presence of symptoms of reflux') as important to measure for the proposed trial.

RESULTS

All parents and most clinicians found the use, dose and duration of omeprazole as the intervention medication, and the placebo control, as acceptable. Parents stated they would hypothetically consent to their child's participation in the trial. Concerns of a few parents and clinicians about infants suffering with symptomatic reflux, and the impact of this for study retention, appeared to be alleviated through the symptomatic reflux treatment pathway. Hesitant clinician views appeared to change through discussion of parental support for the study and by highlighting existing research that questions current practice of PPI treatment.

CONCLUSIONS

Our findings indicate that parents and most clinicians view the proposed Treating Oesophageal Atresia with prophylactic proton pump inhibitors to prevent STricture (TOAST) trial to be feasible and acceptable so long as infants can be given PPI if clinicians deem it clinically necessary. This insight into parent and clinician views and concerns will inform pilot phase trial monitoring, staff training and the development of the trial protocol.

Understanding the healthcare providers' perspective for bringing the assessment of burden of chronic conditions tool to practice: a protocol for an implementation study

INTRODUCTION

The Assessment of Burden of Chronic Conditions (ABCC) tool is developed and validated to support and facilitate a personalised approach to care for people with chronic conditions. The benefit of using the ABCC-tool greatly depends on how it is implemented. To enable a deeper understanding of when, how and by whom the ABCC-tool is used, this study protocol describes the design of an implementation study in which the context, experiences and implementation process of the ABCC-tool by primary care healthcare providers (HCPs) in the Netherlands will be investigated.

METHODS AND ANALYSIS

This protocol describes an implementation study alongside an effectiveness trial, in which the ABCC-tool is evaluated in general practices. The implementation strategy of the tool in the trial confines to providing written information and an instruction video explaining the technical use of the ABCC-tool. The outcomes include a description of: (1) the barriers and facilitators of HCPs for implementation of the ABCC-tool, guided by the Consolidated Framework for Implementation Research (CFIR) and (2) the implementation outcomes guided by the Reach-Effect-Adoption-Implementation-Maintenance (RE-AIM) framework Carroll's fidelity framework. All outcomes will be gathered through individual semistructured interviews throughout 12 months of use. Interviews will be audiorecorded and transcribed. Transcripts will be analysed using content analysis for identifying barriers and facilitators (based on CFIR) and thematic analyses of HCPs' experiences (based on the RE-AIM and the fidelity frameworks).

ETHICS AND DISSEMINATION

The presented study was approved by the Medical Ethics Committee of Zuyderland Hospital, Heerlen (METCZ20180131). Written informed consent is mandatory prior to participation in the study. The results from the study in this protocol will be disseminated through publication in peer-reviewed scientific journals and conference presentations.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

"Are You Safe at Home?": Clinician's Assessments for Intimate Partner Violence at the Initial Obstetric Visit

Few studies have empirically examined patient-clinician conversations to assess how intimate partner violence (IPV) screening is performed. Our study sought to examine audio-recorded first obstetric encounters' IPV screening conversations to describe and categorize communication approaches and explore associations with patient disclosure. We analyzed 247 patient encounters with 47 providers. IPV screening occurred in 95% of visits: 57% used direct questions, 25% used indirect questions, 17% repeated IPV screening later in the visit, 11% framed questions with a reason for asking, and 10% described IPV types. Patients disclosed IPV in 71 (28.7%) visits. There were no associations between disclosure and any categories of IPV screening.

Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis

INTRODUCTION

A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level.

METHODS

This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data.

RESULTS

Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level.

CONCLUSION

The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.

Improving Early Recognition of Coccidioidomycosis in Urgent Care Clinics: Analysis of an Implemented Education Program

Background

Only 0.2% of coccidioidomycosis (CM) diagnoses were made in patients (pts) with pneumonia (PNA) in urgent care (UC), because they were not being tested for CM. Our objective in this study was to improve CM testing rates.

Methods

This was a time series of clinician practice before and after an intervention that occurred at UC clinics in Phoenix and Tucson Arizona. All patients in UC were >18 years old. We included information about CM in periodic educational activities for clinicians. Coccidioidal serologic testing (CST), CST results, and their relation to International Classification of Diseases, Tenth Revision (ICD-10) codes were extracted from medical records.

Results

Urgent care received 2.1 million visits from 1.5 million patients. The CST orders per 10⁴ visits increased from 5.5 to 19.8 (P < .0001). Percentage positive CSTs were highest for August, November, and December (17.0%) versus other months (10.6%). Positive CSTs were associated with PNA ICD-10 codes, and, independently, for Erythema nodosum (EN) which had the highest positivity rate (61.4%). Testing of PNA pts increased on first visits and on second visits when the first CST was negative. Yearly rates of PNA due to CM ranged from 17.3% to 26.0%. Despite this improvement, CST was still not done for over three quarters of pts with PNA. This was a noncomparative study.

Conclusions

Routine quality improvement activities have significantly but only partially improved rates of testing pts with PNA for CM in UC clinics located in a highly endemic area. Innovative strategies may be needed to improve current practice. Also in our region, EN, independent of PNA, is a strong predictor of CM.

A Modified Medical Education Research Study Quality Instrument (MMERSQI) developed by Delphi consensus

BACKGROUND

The Medical Education Research Study Quality Instrument (MERSQI) is widely used to appraise the methodological quality of medical education studies. However, the MERSQI lacks some criteria which could facilitate better quality assessment. The objective of this study is to achieve consensus among experts on: (1) the MERSQI scoring system and the relative importance of each domain (2) modifications of the MERSQI.

METHOD

A modified Delphi technique was used to achieve consensus among experts in the field of medical education. The initial item pool contained all items from MERSQI and items added in our previous published work. Each Delphi round comprised a questionnaire and, after the first iteration, an analysis and feedback report. We modified the quality instruments' domains, items and sub-items and re-scored items/domains based on the Delphi panel feedback.

RESULTS

A total of 12 experts agreed to participate and were sent the first and second-round questionnaires. First round: 12 returned of which 11 contained analysable responses; second-round: 10 returned analysable responses. We started with seven domains with an initial item pool of 12 items and 38 sub-items. No change in the number of domains or items resulted from the Delphi process; however, the number of sub-items increased from 38 to 43 across the two Delphi rounds. In Delphi-2: eight respondents gave 'study design' the highest weighting while 'setting' was given the lowest weighting by all respondents. There was no change in the domains' average weighting score and ranks between rounds.

CONCLUSIONS

The final criteria list and the new domain weighting score of the Modified MERSQI (MMERSQI) was satisfactory to all respondents. We suggest that the MMERSQI, in building on the success of the MERSQI, may help further establish a reference standard of quality measures for many medical education studies.

Association of Tolerance of Uncertainty With Outcomes in a Quality Improvement Collaborative

BACKGROUND

Tolerance of uncertainty may influence how physicians and other providers practice and make clinical decisions. We hypothesized that increased tolerance of uncertainty would be associated with an increased uptake of a quality improvement (QI) intervention.

METHODS

We examined tolerance of uncertainty using the Physicians' Reactions to Uncertainty Scale in the context of a national QI project in the Value in Inpatient Pediatrics network. The QI project aimed to increase exclusive isotonic fluid use and decrease laboratory draws. Exposure to the intervention was measured by using the stepped wedge design with sequential implementation across a diverse group of US hospitals. Multivariable analysis was conducted by using exposure to the intervention and tolerance of uncertainty as independent variables and exclusive isotonic fluid use or laboratory testing as the dependent variable.

RESULTS

Of 106 participating hospitals, 97 contributed valid responses, with an overall mean reported tolerance of uncertainty of 3.39 (95% confidence interval: 3.27-3.50), with lower numbers on the 6-point scale indicating greater tolerance of uncertainty. Exposure to the QI intervention was significantly associated with exclusive isotonic fluid use (P <.001). Lower tolerance of uncertainty at baseline was associated with lower baseline isotonic fluid use and greater uptake of the use of isotonic fluids but not reduction in laboratory testing.

CONCLUSIONS

Contrary to our hypothesis, lower tolerance of uncertainty was associated with greater uptake of the QI intervention for the outcome of isotonic fluids. This initial association warrants further study to evaluate how tolerance of uncertainty plays a role in quality improvement science.

The relative importance of treatment outcomes to surgeons' recommendations for low-risk thyroid cancer

BACKGROUND

The treatment of low-risk thyroid cancer is controversial. We evaluated the importance of treatment outcomes to surgeons' recommendations.

METHODS

A cross-sectional survey asked thyroid surgeons for their treatment recommendations for a healthy 45-year-old patient with a solitary, low-risk, 2-cm papillary thyroid cancer. The importance of the 10 treatment outcomes (survival, recurrence, etc.) to their recommendation was evaluated using constant sum scaling, a method where 100 points are allocated among the treatment outcomes; more points indicate higher importance. The distribution of points was compared between surgeons recommending total thyroidectomy and surgeons recommending lobectomy using Hottelling's T2 test.

RESULTS

Of 165 respondents (74.3% response rate), 35.8% (n = 59) recommended total thyroidectomy and 64.2% (n = 106) lobectomy. The importance of the 10 treatment outcomes was significantly different between groups (P < .05). Surgeons recommending total thyroidectomy were most influenced by the risk of recurrence (19.1 points; standard deviation 16.5) and rated this 1.6-times more important than those recommending lobectomy. Conversely, surgeons recommending lobectomy placed high emphasis on need for hormone replacement (14.3 points; standard deviation 15.4), rating this 3.1-times more important than those recommending total thyroidectomy.

CONCLUSION

Surgeons who recommend total thyroidectomy and those who recommend lobectomy differently prioritize the importance of cancer recurrence and thyroid hormone replacement. Understanding how surgeons' beliefs influence their recommendations is important for ensuring patients receive treatment aligned with their values.

Becoming an Agile Change Conductor

Background

It takes decades and millions of dollars for a new scientific discovery to become part of clinical practice. In 2015, the Center for Health Innovation & Implementation Science (CHIIS) launched a Professional Certificate Program in Innovation and Implementation Sciences aimed at transforming healthcare professionals into Agile Change Conductors capable of designing, implementing, and diffusing evidence-based healthcare solutions.

Method

In 2022, the authors surveyed alumni from the 2016-2021 cohorts of the Certificate Program as part of an educational quality improvement inquiry and to evaluate the effectiveness of the program.

Results

Of the 60 alumni contacted, 52 completed the survey (87% response rate) with 60% of graduates being female while 30% were an under-represented minority. On a scale from 1 to 5, the graduates agreed that the certificate benefited their careers (4.308 with a standard deviation (SD) of 0.612); expanded their professional network (4.615, SD of 0.530); and had a large impact on the effectiveness of their leadership (4.288, SD of 0.667), their change management (4.365, SD of 0.742), and their communication (4.392, SD of 0.666). Graduates claimed to use Agile Processes (Innovation, Implementation, or Diffusion), storytelling, and nudging weekly. On a scale from 0 to 10 where 10 indicates reaching a mastery, the average score for different Agile competencies ranged from 5.37 (SD of 2.80) for drafting business proposals to 7.77 (SD of 1.96) for self-awareness. For the 2020 and 2021 cohorts with existing pre and post training competency data, 22 of the 26 competencies saw a statistically significant increase.

Conclusion

The Graduate Certificate has been able to create a network of Agile Change Conductors competent to design, implement, and diffuse evidence-based care within the healthcare delivery system. Further improvements in building dissemination mastery and program expansion initiatives are advised.

An implementation study of electronic assessment of patient-reported outcomes in inpatient radiation oncology

Purpose

Despite evidence for clinical benefits, recommendations in guidelines, and options for electronic data collection, routine assessment of patient-reported outcomes (PROs) is mostly not implemented in clinical practice. This study aimed to plan, conduct and evaluate the implementation of electronic PRO (e-PRO) assessment in the clinical routine of an inpatient radiation oncology clinic.

Methods

The guideline- and evidence-based, stepwise approach of this single-center implementation study comprised preparatory analyses of current practice, selection of assessment instruments and times, development of staff training, and evidence-based recommendations regarding the use of the e-PRO assessment, as well as on-site support of the implementation. Process evaluation focused on potential clinical benefit (number of documented symptoms and supportive measures), feasibility and acceptance (patient contacts resulting in completion/non-completion of the e-PRO assessment, reasons for non-completion, preconditions, facilitators and barriers of implementation), and required resources (duration of patient contacts to explain/support the completion).

Results

Selection of instruments and assessment times resulted in initial assessment at admission (EORTC QLQ-C30, QSR 10), daily symptom monitoring (EORTC single items), and assessment at discharge (EORTC QLQ-C30). Recommendations for PRO-based clinical action and self-management advice for patients concerning nine core symptoms were developed. Staff training comprised group and face-to-face meetings and an additional e-learning course was developed. Analyses of clinical records showed that e-PRO assessment identified more symptoms followed by a higher number of supportive measures compared to records of patients without e-PRO assessment. Analysis of n = 1597 patient contacts resulted in n = 1355 (84.9%) completed e-PROs (initial assessment: n = 355, monitoring: n = 967, final assessment: n = 44) and n = 242 (15.2%) non-completions. Instructions or support to complete e-PROs took on average 5.5 ± 5.3 min per patient contact. The most challenging issue was the integration of the results in clinical practice.

Conclusion

E-PRO assessment in oncologic inpatient settings is acceptable for patients and can support symptom identification and the initiation of supportive measures. The challenge of making the “data actionable” within the clinical workflow and motivating clinical staff to use the results became evident.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00478-3.

Cancer patients’ perceptions regarding their symptoms and functioning are important as they can differ from a professional assessment. Patients’ perceptions and self-assessment can be collected via electronic devices. Thus, the clinical staff can see a graphic overview of individual disease-related burden. Despite studies indicating the benefit of this assessment for care and symptom management, it is not integrated into routine care so far. The aim of our study was, to plan, conduct and evaluate the implementation of electronic patient-reported assessment in a radio-oncology inpatient clinic under “real-life” clinical conditions instead of study conditions. Patients could complete an electronic assessment at the beginning/end and during their treatment. Results indicate that electronic self-assessment can identify more symptoms than the assessment of physicians and nurses. Patients completing a self-assessment are more likely to receive supportive measures. The majority of 80–90% of patients were willing to complete a self-assessment. On average 5–6 min were needed to explain or support the completion. While the intervention was feasible and acceptable for patients, motivating clinical staff using its results was most challenging. The importance of technical support became evident.

Residual Disease After Primary Surgical Treatment for Advanced Epithelial Ovarian Cancer, Part 2: Network Meta-analysis Incorporating Expert Elicitation to Adjust for Publication Bias

BACKGROUND

Previous work has identified a strong association between the achievements of macroscopic cytoreduction and improved overall survival (OS) after primary surgical treatment of advanced epithelial ovarian cancer. Despite the use of contemporary methodology, resulting in the most comprehensive currently available evidence to date in this area, opponents remain skeptical.

AREAS OF UNCERTAINTY

We aimed to conduct sensitivity analyses to adjust for potential publication bias, to confirm or refute existing conclusions and recommendations, leveraging elicitation to incorporate expert opinion. We recommend our approach as an exemplar that should be adopted in other areas of research.

DATA SOURCES

We conducted random-effects network meta-analyses in frequentist and Bayesian (using Markov Chain Montel Carlo simulation) frameworks comparing OS across residual disease thresholds in women with advanced epithelial ovarian cancer after primary cytoreductive surgery. Elicitation methods among experts in gynecology were used to derive priors for an extension to a previously reported Copas selection model and a novel approach using effect estimates calculated from the elicitation exercise, to attempt to adjust for publication bias and increase confidence in the certainty of the evidence.

THERAPEUTIC ADVANCES

Analyses using data from 25 studies (n = 20,927 women) all showed the prognostic importance of complete cytoreduction (0 cm) in both frameworks. Experts accepted publication bias was likely, but after adjustment for their opinions, published results overpowered the informative priors incorporated into the Bayesian sensitivity analyses. Effect estimates were attenuated but conclusions were robust in all analyses.

CONCLUSIONS

There remains a strong association between the achievement of complete cytoreduction and improved OS even after adjustment for publication bias using strong informative priors formed from an expert elicitation exercise. The concepts of the elicitation survey should be strongly considered for utilization in other meta-analyses.

A survey of colonoscopists with and without in-depth knowledge of water-aided colonoscopy

BACKGROUND AND AIM

Endoscopy featured water-aided colonoscopy (WAC) as novel in the Innovation Forum in 2011. Gastrointestinal Endoscopy published a modified Delphi consensus review (MDCR) that supports WAC for clinical practice in 2021. We tested the hypothesis that experience was an important predictor of WAC use, either as water immersion (WI), water exchange (WE), or a combination of WI and WE.

METHODS

A questionnaire was sent by email to the MDCR authors with an in-depth knowledge of WAC. They responded and also invited colleagues and trainees without in-depth knowledge to respond. Logistic regression analysis was used with the reasons for WAC use treated as the primary outcome. Reports related to WAC post MDCR were identified.

RESULTS

Of 100 respondents, > 80% indicated willingness to adopt and modify practice to accommodate WAC. Higher adenoma detection rate (ADR) incentivized WE use. Procedure time slots ≤ 30 and > 30 min significantly predicted WI and WE use, respectively. Co-authors of the MDCR were significantly more likely to perform WAC (odds ratio [OR] = 7.5, P = 0.037). Unfamiliarity with (OR = 0.11, P = 0.02) and absence of good experience (OR = 0.019, P = 0.002) were associated with colonoscopists less likely to perform WAC. Reports related to WAC post MDCR revealed overall and right colon WE outcomes continued to improve. Network meta-analyses showed that WE was superior to Cap and Endocuff. On-demand sedation with WE shortened nursing recovery time.

CONCLUSIONS

An important predictor of WAC use was experience. Superior outcomes continued to be reported with WE.

Residual disease after primary surgery for advanced epithelial ovarian cancer: expert elicitation exercise to explore opinions about potential impact of publication bias in a planned systematic review and meta-analysis

OBJECTIVES

We consider expert opinion and its incorporation into a planned meta-analysis as a way of adjusting for anticipated publication bias. We conduct an elicitation exercise among eligible British Gynaecological Cancer Society (BGCS) members with expertise in gynaecology.

DESIGN

Expert elicitation exercise.

SETTING

BGCS.

PARTICIPANTS

Members of the BGCS with expertise in gynaecology.

METHODS

Experts were presented with details of a planned prospective systematic review and meta-analysis, assessing overall survival for the extent of excision of residual disease (RD) after primary surgery for advanced epithelial ovarian cancer. Participants were asked views on the likelihood of different studies (varied in the size of the study population and the RD thresholds being compared) not being published. Descriptive statistics were produced and opinions on total number of missing studies by sample size and magnitude of effect size estimated.

RESULTS

Eighteen expert respondents were included. Responders perceived publication bias to be a possibility for comparisons of RD <1 cm versus RD=0 cm, but more so for comparisons involving higher volume suboptimal RD thresholds. However, experts' perceived publication bias in comparisons of RD=0 cm versus suboptimal RD thresholds did not translate into many elicited missing studies in Part B of the elicitation exercise. The median number of missing studies estimated by responders for the main comparison of RD<1 cm versus RD=0 cm was 10 (IQR: 5-20), with the number of missing studies influenced by whether the effect size was equivocal. The median number of missing studies estimated for suboptimal RD versus RD=0 cm was lower.

CONCLUSIONS

The results may raise awareness that a degree of scepticism is needed when reviewing studies comparing RD <1 cm versus RD=0 cm. There is also a belief among respondents that comparisons involving RD=0 cm and suboptimal thresholds (>1 cm) are likely to be impacted by publication bias, but this is unlikely to attenuate effect estimates in meta-analyses.

Implementation of the graduated compression as an adjunct to pharmaco-thromboprophylaxis in surgery trial results across the UK

Objectives

This study aims to examine uptake and dissemination of a National Institute for Health Research (NIHR) Health Technology Assessment (HTA)–funded trial – Graduated compression as an Adjunct to Pharmaco-thromboprophylaxis in Surgery (GAPS) (project number: 14/140/61) amongst health professionals in the UK. This study aims to evaluate the impact of the trial on venous thromboembolism (VTE) prevention policies 7 months after publication.

Method

A 12-question online survey emailed to 2750 individuals via several vascular societies, 34 VTE Exemplar Centre leads and 1 charity over a 3-month period.

Results

In total, 250 responses were received; a 9.1% response rate. Over half of all respondents (52.4%) had read the GAPS trial results prior to completing the survey. Precisely, 77.1% said their hospital had not yet made changes or did not intend to make changes to local hospital VTE policy based on the GAPS trial.

Conclusions

Findings must be interpreted in the context of the low response rate. Further in-depth interviews would aid understanding of barriers to implementing change.

Development of a core measurement set for research in degenerative cervical myelopathy: a study protocol (AO Spine RECODE-DCM CMS)

INTRODUCTION

Progress in degenerative cervical myelopathy (DCM) is hindered by inconsistent measurement and reporting. This impedes data aggregation and outcome comparison across studies. This limitation can be reversed by developing a core measurement set (CMS) for DCM research. Previously, the AO Spine Research Objectives and Common Data Elements for DCM (AO Spine RECODE-DCM) defined 'what' should be measured in DCM: the next step of this initiative is to determine 'how' to measure these features. This protocol outlines the steps necessary for the development of a CMS for DCM research and audit.

METHODS AND ANALYSIS

The CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials and the Consensus-based Standards for the selection of health Measurement Instruments. The process involves five phases. In phase 1, the steering committee agreed on the constructs to be measured by sourcing consensus definitions from patients, professionals and the literature. In phases 2 and 3, systematic reviews were conducted to identify tools for each construct and aggregate their evidence. Constructs with and without tools were identified, and scoping reviews were conducted for constructs without tools. Evidence on measurement properties, as well as on timing of assessments, are currently being aggregated. These will be presented in phase 4: a consensus meeting where a multi-disciplinary panel of experts will select the instruments that will form the CMS. Following selection, guidance on the implementation of the CMS will be developed and disseminated (phase 5). A preliminary CMS review scheduled at 4 years from release.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Cambridge (HBREC2019.14). Dissemination strategies will include peer-reviewed scientific publications; conference presentations; podcasts; the identification of AO Spine RECODE-DCM ambassadors; and engagement with relevant journals, funders and the DCM community.

Clinician Perception of Risk As a Barrier to Implementation of a High-sensitivity Troponin Accelerated Diagnostic Protocol

BACKGROUND

To assess emergency department (ED) clinician perception of patient risk, we measured willingness to discharge patients categorized as increased risk by traditional risk stratification modalities for acute coronary syndrome but low risk by a validated high-sensitivity troponin accelerated diagnostic protocol (HST-ADP).

METHODS

This was a cross-sectional descriptive survey study distributed to ED clinicians at an urban academic medical center. Four clinical vignettes classified hypothetical patients as low risk for 30-day acute coronary syndrome according to the 0-/1-hour HST-ADP. Vignettes additionally identified patients with History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) scores of 4 or 6 (2 cases each). One patient in each subset had preexisting coronary artery disease (CAD). ED clinicians self-reported willingness to discharge patients from the ED on a 10-point Likert scale.

RESULTS

Among 66 eligible participants, 36 (55%) participated in the survey. ED clinicians reported a mean willingness to discharge patients of 6.07 (95% confidence interval, 5.34-6.80). They reported higher mean willingness to discharge patients with HEART scores of 4 compared with those with HEART scores of 6 (mean difference, 3.61; 95% confidence interval, 2.19-5.03). There were no differences in willingness to discharge regarding presence or absence of CAD or between clinician types (attending, resident, advanced practice provider).

CONCLUSIONS

ED clinicians accustomed to the HEART Pathway demonstrated limited willingness to discharge patients from the ED categorized as moderate risk by the HEART score despite simultaneous classification as low risk by the 0-/1-hour HST-ADP. Willingness to discharge was higher with lower HEART scores but not affected by the presence of CAD and did not vary between clinician types.

Fighting Back against Antimicrobial Resistance with Comprehensive Policy and Education: A Narrative Review

Globally, antimicrobial resistance has emerged as a significant threat. A comprehensive plan is required to combat antimicrobial resistance. There have been national and international efforts to address this global health problem, but much work remains. Enhanced funding and regulations to support antimicrobial stewardship policy and program development, reforms to incentivize drug development to treat resistant pathogens, and efforts to strengthen One Health programs are areas for collaboration and innovation. Finally, implementation of educational interventions for trainees encompassing these key areas along with training on policy and leadership development is critical to enable sustainability of these efforts to fight back against antimicrobial resistance.