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Benítez TM, Kim YJ, Kong L, Wang L, Chung KC. Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair. Surgery 2023; 174:1281-1289. [PMID: 37586892 DOI: 10.1016/j.surg.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.
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Affiliation(s)
- Trista M Benítez
- University of Michigan Medical School, Ann Arbor, MI; Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. https://www.twitter.com/benitez_trista
| | - You J Kim
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Rush University Medical College, Chicago, IL. https://www.twitter.com/kim_youj
| | - Lingxuan Kong
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
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Vignarajah M, Berg A, Abdallah Z, Arora N, Javidan A, Pitre T, Fernando SM, Spence J, Centofanti J, Rochwerg B. Intraoperative use of balanced crystalloids versus 0.9% saline: a systematic review and meta-analysis of randomised controlled studies. Br J Anaesth 2023; 131:463-471. [PMID: 37455198 DOI: 10.1016/j.bja.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The evidence regarding optimal crystalloid use in the perioperative period remains unclear. As the primary aim of this study, we sought to summarise the data from RCTs examining whether use of balanced crystalloids compared with 0.9% saline (saline) leads to differences in patient-important outcomes. METHODS We searched Ovid MEDLINE, Embase, the Cochrane library, and Clinicaltrials.gov, from inception until December 15, 2022, and included RCTs that intraoperatively randomised adult participants to receive either balanced fluids or saline. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences (MDs), along with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool, and certainty of evidence using GRADE. RESULTS Of 5959 citations, we included 38 RCTs (n=3776 patients). Pooled analysis showed that intraoperative use of balanced fluids compared with saline had an uncertain effect on postoperative mortality analysed at the longest point of follow-up (RR 1.51, 95% CI: 0.42-5.36) and postoperative need for renal replacement therapy (RR 0.95, 95% CI: 0.56-1.59), both very low certainty. Furthermore, use of balanced crystalloids probably leads to a higher postoperative serum pH (MD 0.05, 95% CI: 0.04-0.06), moderate certainty. CONCLUSIONS Use of balanced crystalloids, compared with saline, in the perioperative setting has an uncertain effect on mortality and need for renal replacement therapy but probably improves postoperative acid-base status. Further research is needed to determine whether balanced crystalloid use affects patient-important outcomes. CLINICAL TRIAL REGISTRATION CRD42022367593.
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Affiliation(s)
| | - Annie Berg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zahra Abdallah
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Naman Arora
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Zhuang T, Shapiro LM, Schultz EA, Truong NM, Harris AHS, Kamal RN. Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline? J Hand Surg Am 2023; 48:19-27. [PMID: 36460552 DOI: 10.1016/j.jhsa.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG. METHODS Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release. RESULTS Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG. CONCLUSIONS The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS. CLINICAL RELEVANCE Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.
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Affiliation(s)
- Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Emily A Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Nicole M Truong
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Alex H S Harris
- Department of Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. METHOD: A scoping review was conducted according to recommendations outlined by Arksey and O'Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. RESULTS The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. CONCLUSIONS Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J. Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO USA
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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Te Velde A, Morgan C, Finch-Edmondson M, McNamara L, McNamara M, Paton MCB, Stanton E, Webb A, Badawi N, Novak I. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis. Pediatrics 2022; 149:188095. [PMID: 35607928 DOI: 10.1542/peds.2021-055061] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP. METHODS Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures. CONCLUSIONS We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.
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Affiliation(s)
- Anna Te Velde
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia.,Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Catherine Morgan
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Megan Finch-Edmondson
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Lynda McNamara
- Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Maria McNamara
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Madison Claire Badawy Paton
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Emma Stanton
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Annabel Webb
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia.,Grace Centre for Newborn Intensive Care, Sydney Children's Hospital Network, The University of Sydney, Westmead, NSW, Australia
| | - Iona Novak
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
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6
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Leigh JP, Sypes EE, Straus SE, Demiantschuk D, Ma H, Brundin-Mather R, de Grood C, FitzGerald EA, Mizen S, Stelfox HT, Niven DJ. Determinants of the de-implementation of low-value care: a multi-method study. BMC Health Serv Res 2022; 22:450. [PMID: 35387673 PMCID: PMC8985316 DOI: 10.1186/s12913-022-07827-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background There is an urgent need to understand the determinants (i.e., barriers and facilitators) of de-implementation. The purpose of this study was to develop a comprehensive list of determinants of the de-implementation of low-value care from the published literature and to compare this list to determinants identified by a group of stakeholders with lived experience with de-implementation. Methods This was a two-phase multi-method study. First, a systematic review examined published barriers and facilitators to de-implementation. Articles were identified through searches within electronic databases, reference lists and the grey literature. Citations were screened independently and in duplicate and included if they were: 1) written in English; and 2) described a barrier or facilitator to de-implementation of any clinical practice in adults (age ≥ 18 years). ‘Raw text’ determinants cited within included articles were extracted and synthesized into a list of representative determinants using conventional content analysis. Second, semi-structured interviews were conducted with decision-makers (unit managers and medical directors) and healthcare professionals working in adult critical care medicine to explore the overlap between the determinants found in the systematic review to those experienced in critical care medicine. Thematic content analysis was used to identify key themes emerging from the interviews. Results In the systematic review, reviewers included 172 articles from 35,368 unique citations. From 437 raw text barriers and 280 raw text facilitators, content analysis produced 29 distinct barriers and 24 distinct facilitators to de-implementation. Distinct barriers commonly cited within raw text included ‘lack of credible evidence to support de-implementation’ (n = 90, 21%), ‘entrenched norms and clinicians’ resistance to change (n = 43, 21%), and ‘patient demands and preferences’ (n = 28, 6%). Distinct facilitators commonly cited within raw text included ‘stakeholder collaboration and communication’ (n = 43, 15%), and ‘availability of credible evidence’ (n = 33, 12%). From stakeholder interviews, 23 of 29 distinct barriers and 20 of 24 distinct facilitators from the systematic review were cited as key themes relevant to de-implementation in critical care. Conclusions The availability and quality of evidence that identifies a clinical practice as low-value, as well as healthcare professional willingness to change, and stakeholder collaboration are common and important determinants of de-implementation and may serve as targets for future de-implementation initiatives. Trial registration The systematic review was registered in PROSPERO CRD42016050234. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07827-4.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Henry Ma
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chloe de Grood
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Emily A FitzGerald
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Sara Mizen
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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Parker G, Shahid N, Rappon T, Kastner M, Born K, Berta W. Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review. Implement Sci 2022; 17:6. [PMID: 35057832 PMCID: PMC8772067 DOI: 10.1186/s13012-021-01177-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. METHODS We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. RESULTS Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. CONCLUSIONS This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.
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Affiliation(s)
- Gillian Parker
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Nida Shahid
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Tim Rappon
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Monika Kastner
- Centre for Research and Innovation, North York General Hospital, 4001, Leslie Street, Toronto, Ontario M2K 1E1 Canada
| | - Karen Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
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Rietbergen T, Marang-van de Mheen PJ, de Graaf J, Diercks RL, Janssen RPA, van der Linden-van der Zwaag HMJ, van den Akker-van Marle ME, Steyerberg EW, Nelissen RGHH, van Bodegom-Vos L, Hofstee DJ, van Geenen RCI, Koenraadt KLM, Onderwater JPAH, Kleinlugtenbelt YV, Gosens T, Klos TVS, Rijk PC, Dijkstra B, Zeegers AVCM, Hoogeslag RAG, Veld MHAHI, Polak AA, Pereira NRP, Vervest TMJS, van der Veen HC, Lopuhaä N. A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:4134-4143. [PMID: 35391552 PMCID: PMC9668785 DOI: 10.1007/s00167-022-06949-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group). METHODS All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016-June 2017) and after introduction of the intervention (July 2017-December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital. RESULTS 136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (β = - 0.15, P < 0.001) and by 0.19% per month for arthroscopy (β = - 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (β = - 0.74, P = 0.228) nor arthroscopy (β = 0.13, P = 0.688). CONCLUSIONS The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands. LEVEL OF EVIDENCE III.
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Affiliation(s)
- T. Rietbergen
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - P. J. Marang-van de Mheen
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - J. de Graaf
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - R. L. Diercks
- grid.4494.d0000 0000 9558 4598Department of Orthopaedics, University Medical Center Groningen, Groningen, The Netherlands
| | - R. P. A. Janssen
- grid.414711.60000 0004 0477 4812Department of Orthopaedic Surgery and Trauma, Maxima Medical Center, Eindhoven, The Netherlands ,grid.6852.90000 0004 0398 8763Orthopaedic Biomechanics, Department Of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands ,grid.448801.10000 0001 0669 4689Chair Value-Based Health Care, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | | | - M. E. van den Akker-van Marle
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - E. W. Steyerberg
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - R. G. H. H. Nelissen
- grid.10419.3d0000000089452978Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - L. van Bodegom-Vos
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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9
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Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Dorée C, Hébert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev 2021; 12:CD002042. [PMID: 34932836 PMCID: PMC8691808 DOI: 10.1002/14651858.cd002042.pub5] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care. OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL). SEARCH METHODS We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised. SELECTION CRITERIA We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed. DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group. MAIN RESULTS A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL. Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders. AUTHORS' CONCLUSIONS Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure. Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Simon J Stanworth
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Nareg Roubinian
- Kaiser Permanente Division of Research Northern California, Oakland, California, USA
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darrell Triulzi
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Paul C Hébert
- Centre for Research, University of Montreal Hospital Research Centre, Montreal, Canada
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10
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Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment. Int J Technol Assess Health Care 2021; 38:e10. [DOI: 10.1017/s0266462321001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).
Objective
The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.
Methods
The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).
Results
There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.
Conclusions
It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.
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11
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Farrugia P. Statistics in Brief: The Cluster Randomized Controlled Trial-What Is It and Why Is It Relevant to Research in Surgery? Clin Orthop Relat Res 2021; 479:1852-1857. [PMID: 34157009 PMCID: PMC8277254 DOI: 10.1097/corr.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/24/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Patricia Farrugia
- Department of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
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12
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Burton CR, Williams L, Bucknall T, Fisher D, Hall B, Harris G, Jones P, Makin M, Mcbride A, Meacock R, Parkinson J, Rycroft-Malone J, Waring J. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background
Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.
Objectives
Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.
Design
A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.
Participants
In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.
Data sources
Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.
Results
The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.
Limitations
Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.
Conclusions
This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.
Study registration
This study is registered as PROSPERO CRD42017081030.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher R Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Lynne Williams
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Denise Fisher
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- Library and Archives Services, Bangor University, Bangor, UK
| | - Gill Harris
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Peter Jones
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Matthew Makin
- North Manchester Care Organisation, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Anne Mcbride
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - John Parkinson
- School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | | | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, UK
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13
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Presseau J, Byrne-Davis LMT, Hotham S, Lorencatto F, Potthoff S, Atkinson L, Bull ER, Dima AL, van Dongen A, French D, Hankonen N, Hart J, Ten Hoor GA, Hudson K, Kwasnicka D, van Lieshout S, McSharry J, Olander EK, Powell R, Toomey E, Byrne M. Enhancing the translation of health behaviour change research into practice: a selective conceptual review of the synergy between implementation science and health psychology. Health Psychol Rev 2021; 16:22-49. [PMID: 33446062 DOI: 10.1080/17437199.2020.1866638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Health psychology is at the forefront of developing and disseminating evidence, theories, and methods that have improved the understanding of health behaviour change. However, current dissemination approaches may be insufficient for promoting broader application and impact of this evidence to benefit the health of patients and the public. Nevertheless, behaviour change theory/methods typically directed towards health behaviours are now used in implementation science to understand and support behaviour change in individuals at different health system levels whose own behaviour impacts delivering evidence-based health behaviour change interventions. Despite contributing to implementation science, health psychology is perhaps doing less to draw from it. A redoubled focus on implementation science in health psychology could provide novel prospects for enhancing the impact of health behaviour change evidence. We report a Health Psychology Review-specific review-of-reviews of trials of health behaviour change interventions published from inception to April 2020. We identified 34 reviews and assessed whether implementation readiness of behaviour change interventions was discussed. We then narratively review how implementation science has integrated theory/methods from health psychology and related discipline. Finally, we demonstrate how greater synergy between implementation science and health psychology could promote greater follow-through on advances made in the science of health behaviour change.
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Affiliation(s)
- Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,School of Psychology, University of Ottawa, Ottawa, Canada
| | | | - Sarah Hotham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | | | - Sebastian Potthoff
- Department of Social Work, Education, and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Lou Atkinson
- School of Psychology, Aston University, Birmingham, UK
| | - Eleanor R Bull
- Research Centre for Health, Psychology and Communities, Manchester Metropolitan University, Manchester, UK
| | - Alexandra L Dima
- Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France
| | | | - David French
- School of Health Sciences & Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Nelli Hankonen
- Social Psychology, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Jo Hart
- Division of Medical Education, University of Manchester, Manchester, UK
| | - Gill A Ten Hoor
- Dept of Work & Social Psychology, Maastricht University, Maastricht, The Netherlands.,Dept of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Houston, TX, USA
| | - Kristian Hudson
- Centre for Aging and Rehabilitation, Bradford Institute for Health Research, Bradford, UK
| | - Dominika Kwasnicka
- Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland.,NHMRC CRE in Digital Technology to Transform Chronic Disease Outcomes, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Sanne van Lieshout
- Team Advies & Onderzoek, Municipal Health Service (GGD) Kennemerland, Haarlem, the Netherlands
| | - Jennifer McSharry
- Health Behaviour Change Research Group, National University of Ireland, Galway, Ireland
| | - Ellinor K Olander
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, United Kingdom
| | - Rachael Powell
- School of Health Sciences & Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Elaine Toomey
- Health Behaviour Change Research Group, National University of Ireland, Galway, Ireland.,School of Allied Health, University of Limerick, Limerick, Ireland
| | - Molly Byrne
- Health Behaviour Change Research Group, National University of Ireland, Galway, Ireland
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14
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Cotterill S, Tang MY, Powell R, Howarth E, McGowan L, Roberts J, Brown B, Rhodes S. Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background
A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.
Objective
To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.
Design
A systematic review and meta-analysis of randomised controlled trials.
Data sources
The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).
Participants
Health workers took part in the study.
Interventions
Behaviour change interventions based on social norms.
Outcome measures
Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.
Methods
Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.
Results
A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I
2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).
Limitations
The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.
Conclusions
Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.
Future work
Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.
Study registration
This study is registered as PROSPERO CRD42016045718.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sarah Cotterill
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mei Yee Tang
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachael Powell
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth Howarth
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Laura McGowan
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jane Roberts
- Outreach and Evidence Search Service, Library and E-learning Service, Northern Care Alliance, NHS Group, Royal Oldham Hospital, Oldham, UK
| | - Benjamin Brown
- Health e-Research Centre, Farr Institute for Health Informatics Research, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Rhodes
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Kang BX, Xu H, Gao CX, Zhong S, Zhang J, Xie J, Sun ST, Ma YH, Zhai WT, Xiao LB. Multiple-dose tranexamic acid for perioperative blood loss in total knee arthroplasty in patients with rheumatoid arthritis:a single-blinded, randomised, parallel-controlled study protocol in China. BMJ Open 2020; 10:e034431. [PMID: 32819929 PMCID: PMC7440821 DOI: 10.1136/bmjopen-2019-034431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 05/23/2020] [Accepted: 06/26/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION This clinical trial is designed to evaluate the effect of multiple-dose tranexamic acid (TXA) on perioperative blood loss in patients with rheumatoid arthritis (RA). METHODS AND ANALYSIS A randomised, single-blinded, parallel-controlled study will be designed. Patients with RA (age 50-75 years) undergoing unilateral primary end-stage total knee arthroplasty will be randomly divided into group A or group B. Group A will be treated with one dose of TXA (1 g; intravenous injection 3 hours postsurgery) and group B with three doses (1 g; intravenous injection at 3, 6 and 12 hours postsurgery) after surgery. The primary outcomes will be evaluated with blood loss, maximum haemoglobin drop and transfusion rate. The secondary outcomes will be evaluated with knee function and complications. ETHICS AND DISSEMINATION The Shanghai Guanghua Hospital of Integrated Traditional Chinese Medicine and Western Medicine Ethics Committee approved in this study in July 2019. Informed consent will be obtained from all participants. Results of the trial will be published in the Dryad and repository in a peer-reviewed journal. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER ChiCTR1900025013.
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Affiliation(s)
- Bing-Xin Kang
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hui Xu
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chen-Xin Gao
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Sheng Zhong
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jing Zhang
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jun Xie
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Song-Tao Sun
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ying-Hui Ma
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wei-Tao Zhai
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lian-Bo Xiao
- Orthopaedics, ShangHai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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16
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Fahim C, Acai A, McConnell MM, Wright FC, Sonnadara RR, Simunovic M. Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making. BMC Health Serv Res 2020; 20:578. [PMID: 32580767 PMCID: PMC7313182 DOI: 10.1186/s12913-020-05255-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/27/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Multidisciplinary Cancer Conferences (MCCs) are prospective meetings involving cancer specialists to discuss treatment plans for patients with cancer. Despite reported gaps in MCC quality, there have been few efforts to improve its functioning. The purpose of this study was to use theoretically-rooted knowledge translation (KT) theories and frameworks to inform the development of a strategy to improve MCC decision-making quality. METHODS A multi-phased approach was used to design an intervention titled the KT-MCC Strategy. First, key informant interviews framed using the Theoretical Domains Framework (TDF) were conducted with MCC participants to identify barriers and facilitators to optimal MCC decision-making. Second, identified TDF domains were mapped to corresponding strategies using the COM-B Behavior Change Wheel to develop the KT-MCC Strategy. Finally, focus groups with MCC participants were held to confirm acceptability of the proposed KT-MCC Strategy. RESULTS Data saturation was reached at n = 21 interviews. Twenty-seven barrier themes and 13 facilitator themes were ascribed to 11 and 10 TDF domains, respectively. Differences in reported barriers by physician specialty were observed. The resulting KT-MCC Strategy included workshops, chair training, team training, standardized intake forms and a synoptic discussion checklist, and, audit and feedback. Focus groups (n = 3, participants 18) confirmed the acceptability of the identified interventions. CONCLUSION Myriad factors were found to influence MCC decision making. We present a novel application of the TDF and COM-B to the context of MCCs. We comprehensively describe the barriers and facilitators that impact MCC decision making and propose strategies that may positively impact the quality of MCC decision making.
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Affiliation(s)
- Christine Fahim
- Department of Health Research Methods, McMaster University, Evidence and Impact, Hamilton, ON, Canada. .,Johns Hopkins University, Bloomberg School of Public Health, Hampton House, Room 663, 624 N Broadway, Baltimore, MD, 21205, USA.
| | - Anita Acai
- Department of Surgery, McMaster University, Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Meghan M McConnell
- Department of Innovation in Medical Education, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada
| | - Frances C Wright
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto Room T2 057, 2075 Bayview Ave., Toronto, ON, M4N 3M5, Canada
| | - Ranil R Sonnadara
- Department of Surgery, McMaster University, Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Marko Simunovic
- Department of Health Research Methods, McMaster University, Evidence and Impact, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
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Allen P, Jacob RR, Parks RG, Mazzucca S, Hu H, Robinson M, Dobbins M, Dekker D, Padek M, Brownson RC. Perspectives on program mis-implementation among U.S. local public health departments. BMC Health Serv Res 2020; 20:258. [PMID: 32228688 PMCID: PMC7106610 DOI: 10.1186/s12913-020-05141-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 03/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Public health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments. METHODS The national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert). RESULTS Thirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%). CONCLUSIONS Organizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.
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Affiliation(s)
- Peg Allen
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA.
| | - Rebekah R Jacob
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
| | - Renee G Parks
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
| | - Stephanie Mazzucca
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
| | - Hengrui Hu
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
| | - Mackenzie Robinson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
| | - Maureen Dobbins
- National Collaborating Centre for Methods and Tools, McMaster University, McMaster Innovation Park (MIP), 175 Longwood Road South, Suite 210a, Hamilton, Ontario, L8P 0A1, Canada
| | - Debra Dekker
- National Association of County and City Health Officials (NACCHO), 1201 Eye Street, NW, 4th Floor, Washington, DC, 20005, USA
| | - Margaret Padek
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130-4838, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine; Washington University in St. Louis, 4921 Parkview Place, St. Louis, MO, 63110, USA
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18
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Barlow T, Rhodes-Jones T, Ballinger S, Metcalfe A, Wright D, Thompson P. Decreasing the number of arthroscopies in knee osteoarthritis - a service evaluation of a de-implementation strategy. BMC Musculoskelet Disord 2020; 21:140. [PMID: 32126992 PMCID: PMC7055049 DOI: 10.1186/s12891-020-3125-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Personalised Knee Improvement Programme (P-KIP) was developed based on previously published work, with the hypothesis that surgeons would refer patients to a well-structured conservative management intervention instead of for arthroscopy (de-implementation of arthroscopy by substitution with P-KIP). This meets NICE guidelines and international recommendations but such programmes are not widely used in the UK. Our aim was to determine whether P-KIP would reduce the number of arthroscopies performed for knee osteoarthritis. METHODS P-KIP is a conservative care pathway including a group education session followed by individually tailored one-to-one dietician and physiotherapy sessions. Virtual clinic follow-up is conducted three to 6 months after completion of the programme. The service began in July 2015. The number of arthroscopies saved, measured from hospital level coding data, is the primary outcome measure. Interrupted time series analysis of coding data was conducted. As a quality assurance process, patient reported outcome measures (Oxford Knee Score; Euroqol 5D) were collected at baseline and at follow up. RESULTS Time series analysis demonstrates that the programme saved 15.4 arthroscopies a month (95% confidence interval 9-21; p < 0.001), equating to 184 arthroscopies a year in a single hospital. The PROMs data demonstrated improvements in patient reported outcome scores consistent with previous published reports of conservative interventions in similar patient populations. CONCLUSIONS Results suggest that P-KIP reduces the number of arthroscopies performed, and patients who took part in P-KIP had an improvement in their knee and general health outcomes. P-KIP has the potential to deliver efficiency savings and relive pressure on operative lists, however replication in other sites is required.
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Affiliation(s)
- Timothy Barlow
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
- Clinical Sciences Research Laboratories, Warwick University UHCW, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Timothy Rhodes-Jones
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Sue Ballinger
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Andrew Metcalfe
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
- Clinical Sciences Research Laboratories, Warwick University UHCW, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - David Wright
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Peter Thompson
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
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19
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Smith ME, Vitous CA, Hughes TM, Shubeck SP, Jagsi R, Dossett LA. Barriers and Facilitators to De-Implementation of the Choosing Wisely ® Guidelines for Low-Value Breast Cancer Surgery. Ann Surg Oncol 2020; 27:2653-2663. [PMID: 32124126 DOI: 10.1245/s10434-020-08285-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND To address overuse of unnecessary practices, several surgical organizations have participated in the Choosing Wisely® campaign and identified four breast cancer surgical procedures as unnecessary. Despite evidence demonstrating no survival benefit for all four, evidence suggests only two have been substantially de-implemented. Our objective was to understand why surgeons stop performing certain unnecessary cancer operations but not others and how best to de-implement entrenched and emerging unnecessary procedures. METHODS We sampled surgeons who treat breast cancer in a variety of practice types and geographic regions in the United States. Using a semi-structured guide, we conducted telephone interviews (n = 18) to elicit attitudes and understand practices relating to the four identified breast cancer procedures in the Choosing Wisely® campaign. Interviews were recorded, transcribed, and anonymized. Transcripts were analyzed using inductive and deductive thematic analysis. RESULTS For the two procedures successfully de-implemented, surgeons described a high level of confidence in the data supporting the recommendations. In contrast, surgeons frequently described a lack of familiarity or skepticism toward the recommendation to avoid sentinel-node biopsy in women ≥ 70 years of age and the influence of other collaborating oncology providers as justification for continued use. Regarding contralateral prophylactic mastectomy, surgeons consistently agreed with the recommendation that this was unnecessary, yet reported continued utilization due to the value placed on patient autonomy and preference. CONCLUSIONS With a growing focus on the elimination of ineffective, unproven or low value practices, it is imperative that the behavioral determinants are understood and targeted with specific interventions to decrease utilization rapidly.
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Affiliation(s)
- Margaret E Smith
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah P Shubeck
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
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20
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Comparative Analysis Investigating the Impact of Implant Design on Hospital Length of Stay and Discharge Destination in a Dutch Hospital With an Established Enhanced Recovery Program. J Arthroplasty 2020; 35:182-187. [PMID: 31522851 DOI: 10.1016/j.arth.2019.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Global demand for total knee arthroplasty (TKA) is increasing, driven by an aging and increasingly overweight patient population, culminating in higher healthcare costs. In the Netherlands, the number of TKA surgeries performed annually increased from 21,000 in 2010 to 29,000 in 2017. This study aimed to assess the impact of implant design on hospital length of stay (LOS), surgery time, and discharge destination (home vs a rehabilitation center) in a Dutch hospital with an established enhanced recovery program and short baseline LOS. METHODS A retrospective review of consecutive adult patients who underwent primary TKA in a Dutch hospital between 2015 and 2017 using either the comparator device or the control device. RESULTS A total of 200 patients were enrolled in the study (100 per group). Patients who received a comparator device had a significantly shorter LOS (adjusted mean 2.76 days; 95% confidence interval [CI]: 2.45, 3.11) vs the control group (adjusted mean 3.43 days; 95% CI: 3.08, 3.81; P < .01). The proportion of patients discharged to a rehabilitation center, instead of home, was also significantly lower in the comparator device group (adjusted 4.4%; 95% CI: 1.8, 10.7 vs adjusted 11.4%; 95% CI: 6.0, 20.6; P < .05). There was no difference in surgical time between the 2 groups. None of the sensitivity analyses performed affected the original analysis outcome. CONCLUSION This study shows a modest but significant reduction in length of stay and lower rate of discharge to a rehabilitation center in the comparator device group.
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21
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Pennestrì F, Maffulli N, Sirtori P, Perazzo P, Negrini F, Banfi G, Peretti GM. Blood management in fast-track orthopedic surgery: an evidence-based narrative review. J Orthop Surg Res 2019; 14:263. [PMID: 31429775 PMCID: PMC6701001 DOI: 10.1186/s13018-019-1296-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. METHODS AND MATERIALS We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. RESULTS Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. CONCLUSION The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.
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Affiliation(s)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy. .,San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Orthopedica" Department, Hospital of Salerno, Salerno, Italy. .,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, London, England.
| | - Paolo Sirtori
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Paolo Perazzo
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Francesco Negrini
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,Vita-Salute San Raffaele University, Scientific Direction, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,University of Milan, Department of Biomedical Sciences for Health, Milan, Italy
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22
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Patey AM, Hurt CS, Grimshaw JM, Francis JJ. Changing behaviour 'more or less'-do theories of behaviour inform strategies for implementation and de-implementation? A critical interpretive synthesis. Implement Sci 2018; 13:134. [PMID: 30373635 PMCID: PMC6206907 DOI: 10.1186/s13012-018-0826-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 10/17/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Implementing evidence-based care requires healthcare practitioners to do less of some things (de-implementation) and more of others (implementation). Variations in effectiveness of behaviour change interventions may result from failure to consider a distinction between approaches by which behaviour increases and decreases in frequency. The distinction is not well represented in methods for designing interventions. This review aimed to identify whether there is a theoretical rationale to support this distinction. METHODS Using Critical Interpretative Synthesis, this conceptual review included papers from a broad range of fields (biology, psychology, education, business) likely to report approaches for increasing or decreasing behaviour. Articles were identified from databases using search terms related to theory and behaviour change. Articles reporting changes in frequency of behaviour and explicit use of theory were included. Data extracted were direction of behaviour change, how theory was operationalised, and theory-based recommendations for behaviour change. Analyses of extracted data were conducted iteratively and involved inductive coding and critical exploration of ideas and purposive sampling of additional papers to explore theoretical concepts in greater detail. RESULTS Critical analysis of 66 papers and their theoretical sources identified three key findings: (1) 9 of the 15 behavioural theories identified do not distinguish between implementation and de-implementation (5 theories were applied to only implementation or de-implementation, not both); (2) a common strategy for decreasing frequency was substituting one behaviour with another. No theoretical basis for this strategy was articulated, nor were methods proposed for selecting appropriate substitute behaviours; (3) Operant Learning Theory makes an explicit distinction between techniques for increasing and decreasing frequency. DISCUSSION Behavioural theories provide little insight into the distinction between implementation and de-implementation. Operant Learning Theory identified different strategies for implementation and de-implementation, but these strategies may not be acceptable in health systems. Additionally, if behaviour substitution is an approach for de-implementation, further investigation may inform methods or rationale for selecting the substitute behaviour.
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Affiliation(s)
- Andrea M. Patey
- School of Health Sciences, City, University of London, 10 Northampton Square, London, EC1V 0HB UK
- Centre for Implementation Research, Ottawa Hospital Research Institute – General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Catherine S. Hurt
- School of Health Sciences, City, University of London, 10 Northampton Square, London, EC1V 0HB UK
| | - Jeremy M. Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute – General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
- Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada
| | - Jill J. Francis
- School of Health Sciences, City, University of London, 10 Northampton Square, London, EC1V 0HB UK
- Centre for Implementation Research, Ottawa Hospital Research Institute – General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
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23
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McKay VR, Morshed AB, Brownson RC, Proctor EK, Prusaczyk B. Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2018; 62:189-202. [PMID: 29971792 PMCID: PMC6175194 DOI: 10.1002/ajcp.12258] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The discontinuation of interventions that should be stopped, or de-implementation, has emerged as a novel line of inquiry within dissemination and implementation science. As this area grows in human services research, like public health and social work, theory is needed to help guide scientific endeavors. Given the infancy of de-implementation, this conceptual narrative provides a definition and criteria for determining if an intervention should be de-implemented. We identify three criteria for identifying interventions appropriate for de-implementation: (a) interventions that are not effective or harmful, (b) interventions that are not the most effective or efficient to provide, and (c) interventions that are no longer necessary. Detailed, well-documented examples illustrate each of the criteria. We describe de-implementation frameworks, but also demonstrate how other existing implementation frameworks might be applied to de-implementation research as a supplement. Finally, we conclude with a discussion of de-implementation in the context of other stages of implementation, like sustainability and adoption; next steps for de-implementation research, especially identifying interventions appropriate for de-implementation in a systematic manner; and highlight special ethical considerations to advance the field of de-implementation research.
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Affiliation(s)
- Virginia R. McKay
- Center for Public Health Systems ScienceBrown SchoolWashington University in St. LouisSt. LouisMOUSA
- Institute of Clinical and Translational ScienceWashington University School of Medicine in St. LouisSt. LouisMOUSA
| | - Alexandra B. Morshed
- Prevention Research Center in St. LouisBrown SchoolWashington University in St. LouisSt. LouisMOUSA
| | - Ross C. Brownson
- Prevention Research Center in St. LouisBrown SchoolWashington University in St. LouisSt. LouisMOUSA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer CenterWashington University School of MedicineWashington University in St. LouisSt. LouisMOUSA
| | - Enola K. Proctor
- Institute of Clinical and Translational ScienceWashington University School of Medicine in St. LouisSt. LouisMOUSA
- Center for Mental Health Services ResearchGeorge Warren Brown School of Social WorkWashington University in St. LouisSt. LouisMOUSA
- Institute for Public HealthWashington University in St. LouisSt. LouisMOUSA
| | - Beth Prusaczyk
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Center for Clinical Quality and Implementation ResearchVanderbilt University Medical CenterNashvilleTNUSA
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Abstract
AIM The purpose of this concept analysis is to explore the meaning of de-implementation and provide a definition that can be used by researchers and clinicians to facilitate evidence-based practice. BACKGROUND De-implementation is a relatively unknown process overshadowed by the novelty of introducing new ideas and techniques into practice. Few studies have addressed the challenge of de-implementation and the cognitive processes involved when terminating harmful or unnecessary practices. Also, confusion exists regarding the myriad of terms used to describe de-implementation processes. DESIGN Walker and Avant's method (2011) for describing concepts was used to clarify de-implementation. DATA SOURCE A database search limited to academic journals yielded 281 publications representing basic research, study protocols, and editorials/commentaries from implementation science experts. After applying exclusion criterion of English language only and eliminating overlap between databases, 41 articles were selected for review. REVIEW METHODS Literature review and synthesis provided a concept analysis and a distinct definition of de-implementation. RESULTS De-implementation was defined as the process of identifying and removing harmful, non-cost-effective, or ineffective practices based on tradition and without adequate scientific support. CONCLUSIONS The analysis provided further refinement of de-implementation as a significant concept for ongoing theory development in implementation science and clinical practice.
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25
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Voorn VMA, van Bodegom-Vos L, So-Osman C. Towards a systematic approach for (de)implementation of patient blood management strategies. Transfus Med 2018; 28:158-167. [PMID: 29508467 DOI: 10.1111/tme.12520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.
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Affiliation(s)
- V M A Voorn
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.,Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - L van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - C So-Osman
- Unit Transfusion Medicine, Sanquin, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
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Helfrich CD, Rose AJ, Hartmann CW, van Bodegom-Vos L, Graham ID, Wood SJ, Majerczyk BR, Good CB, Pogach LM, Ball SL, Au DH, Aron DC. How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution. J Eval Clin Pract 2018; 24:198-205. [PMID: 29314508 PMCID: PMC5900912 DOI: 10.1111/jep.12855] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.
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Affiliation(s)
- Christian D Helfrich
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Adam J Rose
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR) Bedford VA Medical Center, Bedford, USA.,Boston University School of Public Health, Boston, USA
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Suzanne J Wood
- Graduate Program in Health Services Administration, Department of Health Sciences, School of Public Health, University of Washington, Seattle, USA
| | - Barbara R Majerczyk
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh healthcare System, Department of Veterans Affairs, Pittsburgh, USA.,Medical Advisory Panel for Pharmacy Benefits Management, Department of Veterans Affairs, Washington, USA.,University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Leonard M Pogach
- Office of Specialty Care, Veterans Health Administration, Washington, USA.,VA New Jersey Health Care System, East Orange, USA
| | - Sherry L Ball
- Louis Stokes Cleveland VA Medical Center, Department of Veterans Affairs, Cleveland, USA
| | - David H Au
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, USA
| | - David C Aron
- Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, USA.,Division of Clinical and Molecular Endocrinology and Adjunct Professor Dept. of Organizational Behavior, Weatherhead School of Management, Case Western Reserve University, Cleveland, USA
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