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Mead ES, Teeling SP, McNamara M. A Realist Review Protocol into the Contexts and Mechanisms That Enable the Inclusion of Environmental Sustainability Outcomes in the Design of Lean Healthcare Improvement Interventions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:868. [PMID: 39063445 PMCID: PMC11276605 DOI: 10.3390/ijerph21070868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 07/28/2024]
Abstract
Healthcare makes a significant contribution to the social, economic and environmental benefits of communities. It is correspondingly a significant employer and consumer of both energy and consumables, often at high costs. Lean, a quality improvement methodology focuses on the elimination of non-value add (NVA) activities (steps that do not add value from the perspective of the customer) to improve the flow of people, information or goods. Increasingly, Lean thinking is evolving from its initial focus on eliminating NVA to a more holistic approach that encompasses sustainability. However, little work has been undertaken intentionally, including environmental sustainability outcomes in Lean healthcare interventions. Realist review methodology facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how, and has proven useful in research relating to Lean interventions in healthcare settings. This protocol provides details for a realist review that will enable an understanding of the specific contexts in which certain mechanisms are activated that enable the inclusion of environmental sustainability outcomes in the design of Lean healthcare improvement interventions.
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Affiliation(s)
- Elaine Shelford Mead
- UCD Centre for Interdisciplinary Research, Education & Innovation in Health Systems, School of Nursing, Midwifery & Health Systems UCD Health Sciences Centre, D04 VIW8 Dublin, Ireland
| | - Seán Paul Teeling
- UCD Centre for Interdisciplinary Research, Education & Innovation in Health Systems, School of Nursing, Midwifery & Health Systems UCD Health Sciences Centre, D04 VIW8 Dublin, Ireland
- Centre for Person-Centered Practice Research Division of Nursing, School of Health Sciences, Queen Margaret University, Queen Margaret University Drive, Musselburgh EH21 6UU, UK
| | - Martin McNamara
- UCD Centre for Interdisciplinary Research, Education & Innovation in Health Systems, School of Nursing, Midwifery & Health Systems UCD Health Sciences Centre, D04 VIW8 Dublin, Ireland
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Abboud J, Shaikh N, Moosa M, Dempster M, Adair P. Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement. Int J Qual Health Care 2024; 36:mzae019. [PMID: 38468470 PMCID: PMC10928308 DOI: 10.1093/intqhc/mzae019] [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: 10/16/2023] [Revised: 01/11/2024] [Accepted: 02/20/2024] [Indexed: 03/13/2024] Open
Abstract
Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.
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Affiliation(s)
- Juliana Abboud
- Centre for Improving Health Related Quality of Life, School of Psychology, Queens University Belfast, David Keir Building, 18-30 Malone Road, Belfast BT9 5BN, United Kingdom
- Rashid Hospital, Dubai Academic Health Corporation, Umm Hurair II 315, PO Box 7272, Dubai, United Arab Emirates
| | - Niaz Shaikh
- Rashid Hospital, Dubai Academic Health Corporation, Umm Hurair II 315, PO Box 7272, Dubai, United Arab Emirates
| | - Musthafa Moosa
- Rashid Hospital, Dubai Academic Health Corporation, Umm Hurair II 315, PO Box 7272, Dubai, United Arab Emirates
| | - Martin Dempster
- Centre for Improving Health Related Quality of Life, School of Psychology, Queens University Belfast, David Keir Building, 18-30 Malone Road, Belfast BT9 5BN, United Kingdom
| | - Pauline Adair
- Centre for Improving Health Related Quality of Life, School of Psychology, Queens University Belfast, David Keir Building, 18-30 Malone Road, Belfast BT9 5BN, United Kingdom
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Koole SN, Huisman AH, Timmers L, Westgeest HM, van Breugel E, Sonke GS, van Waalwijk van Doorn-Khosrovani SB. Lessons learned from postmarketing withdrawals of expedited approvals for oncology drug indications. Lancet Oncol 2024; 25:e126-e135. [PMID: 38423058 DOI: 10.1016/s1470-2045(23)00592-2] [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: 09/18/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 03/02/2024]
Abstract
In the past decade, there have been a record number of oncology therapy approvals by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Besides the EMA's conditional marketing authorisation programme and the FDA's Accelerated Approval Program, we observe a tendency towards fast approval for exploratory studies with non-randomised, uncontrolled designs and surrogate endpoints. This issue raises concerns about the robustness and effectiveness of accepted treatments, leaving patients and health-care professionals in a state of uncertainty. A substantial number of accelerated approvals have recently been withdrawn in the USA, with some still authorised in Europe, emphasising discrepancies in regulatory standards that affect both patients and society as a whole. We highlight examples of drugs, authorised on the basis of surrogate endpoints, that were later withdrawn due to an absence of overall survival benefit. Our findings address the challenges and consequences of accelerated approval pathways in oncology. In conclusion, this Policy Review calls for regulatory bodies to better align their procedures and insist on robust evidence, preferably through unbiased randomised controlled trials. Drug approval processes should prioritise patient benefit, overall survival, and quality of life to minimise risks and uncertainties for patients.
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Affiliation(s)
- Simone N Koole
- Medical Advisory Department, ONVZ Health Insurance, Houten, Netherlands.
| | | | - Lonneke Timmers
- Care Department, National Health Care Institute, Diemen, Netherlands
| | - Hans M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, Netherlands
| | - Edwin van Breugel
- Medical Advisory Department, VGZ Health Insurance, Arnhem, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Frontera WR, Cordani C, Décary S, DE Groote W, Del Furia MJ, Feys P, Jette AM, Kiekens C, Negrini S, Oral A, Resnik L, Røe C, Sabariego C. Relevance and use of health policy, health systems and health services research for strengthening rehabilitation in real-life settings: methodological considerations. Eur J Phys Rehabil Med 2024; 60:154-163. [PMID: 38252128 PMCID: PMC10938940 DOI: 10.23736/s1973-9087.24.08386-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
Research on health policy, systems, and services (HPSSR) has seen significant growth in recent decades and received increasing attention in the field of rehabilitation. This growth is driven by the imperative to effectively address real-life challenges in complex healthcare settings. A recent resolution on 'Strengthening rehabilitation in health systems' adopted by the World Health Assembly emphasizes the need to support societal health goals related to rehabilitation, particularly to promote high-quality rehabilitation research, including HPSSR. This conceptual paper, discussed with the participants in the 5th Cochrane Rehabilitation Methodological Meeting held in Milan on September 2023, outlines study designs at diverse levels at which HPSSR studies can be conducted: the macro, meso, and micro levels. It categorizes research questions into four types: those framed from the perspective of policies, healthcare delivery organizations or systems, defined patient or provider populations, and important data sources or research methods. Illustrative examples of appropriate methodologies are provided for each type of research question, demonstrating the potential of HPSSR in shaping policies, improving healthcare delivery, and addressing patient and provider perspectives. The paper concludes by discussing the applicability, usefulness, and implementation of HPSSR findings, and the importance of knowledge translation strategies, drawing insights from implementation science. The goal is to facilitate the integration of research findings into everyday clinical practice to bridge the gap between research and practice in rehabilitation.
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Affiliation(s)
- Walter R Frontera
- Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Claudio Cordani
- Department of Biomedical, Surgical and Dental Sciences, University "La Statale", Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Simon Décary
- Faculty of Medicine and Health Sciences, School of Rehabilitation, Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Wouter DE Groote
- Rehabilitation Programme, Department for Noncommunicable Diseases, Sensory Functions, Disability and Rehabilitation Unit, World Health Organization, Geneva, Switzerland
| | - Matteo J Del Furia
- Department of Biomedical, Surgical and Dental Sciences, University "La Statale", Milan, Italy -
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Peter Feys
- Faculty of Rehabilitation Sciences, University of Hasselt, REVAL Rehabilitation Research Center, Diepenbeek, Belgium
| | - Alan M Jette
- Boston University's Sargent College of Health & Rehabilitation Sciences, Boston, MA, USA
| | | | - Stefano Negrini
- Department of Biomedical, Surgical and Dental Sciences, University "La Statale", Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Aydan Oral
- Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Linda Resnik
- Department of Health Services, Policy and Practice, Brown University and Research Career Scientist VA Medical Center, Providence, RI, USA
| | - Cecilie Røe
- Department of Physical Medicine and Rehabilitation, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Carla Sabariego
- Swiss Paraplegic Research, Nottwil, Faculty of Health Sciences and Medicine and Center for Rehabilitation in Global Health Systems, University of Lucerne, Lucerne, Switzerland
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Conway A, Marshall AD, Crawford S, Hayllar J, Grebely J, Treloar C. Deimplementation in the provision of opioid agonist treatment to achieve equity of care for people engaged in treatment: a qualitative study. Implement Sci 2023; 18:22. [PMID: 37296448 DOI: 10.1186/s13012-023-01281-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic. METHODS Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access. RESULTS We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses. CONCLUSIONS The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.
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Affiliation(s)
- Anna Conway
- The Kirby Institute, UNSW, Sydney, Australia.
- Centre for Social Research in Health, UNSW, Sydney, Australia.
| | - Alison D Marshall
- The Kirby Institute, UNSW, Sydney, Australia
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | | | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, Australia
| | | | - Carla Treloar
- Centre for Social Research in Health, UNSW, Sydney, Australia
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Pittet LF, Glangetas A, Barazzone-Argiroffo C, Gervaix A, Posfay-Barbe KM, Galetto-Lacour A, Stollar F. Factors associated with nonadherence to the American Academy of Pediatrics 2014 bronchiolitis guidelines: A retrospective study. PLoS One 2023; 18:e0285626. [PMID: 37200253 DOI: 10.1371/journal.pone.0285626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/26/2023] [Indexed: 05/20/2023] Open
Abstract
The latest guideline from the American Academy of Pediatrics for the management of bronchiolitis has helped reduce unnecessary interventions and costs. However, data on patients still receiving interventions are missing. In patients with acute bronchiolitis whose management was assessed and compared with current achievable benchmarks of care, we aimed to identify factors associated with nonadherence to guideline recommendations. In this single-centre retrospective study the management of bronchiolitis pre-guideline (Period 1: 2010 to 2012) was compared with two periods post-guideline (Period 2: 2015 to 2016, early post-guideline; and Period 3: 2017 to 2018, late post-guideline) in otherwise healthy infants aged less than 1 year presenting at the Children's University Hospitals of Geneva (Switzerland). Post-guideline, bronchodilators were more frequently administered to older (>6 months; OR 25.8, 95%CI 12.6-52.6), and atopic (OR 3.5, 95%CI 1.5-7.5) children with wheezing (OR 5.4, 95%CI 3.3-8.7). Oral corticosteroids were prescribed more frequently to older (>6 months; OR 5.2, 95%CI 1.4-18.7) infants with wheezing (OR 4.9, 95% CI 1.3-17.8). Antibiotics and chest X-ray were more frequently prescribed to children admitted to the intensive care unit (antibiotics: OR 4.2, 95%CI 1.3-13.5; chest X-ray: OR 19.4, 95%CI 7.4-50.6). Latest prescription rates were all below the achievable benchmarks of care. In summary, following the latest American Academy of Pediatrics guideline, older, atopic children with wheezing and infants admitted to the intensive care unit were more likely to receive nonevidence-based interventions during an episode of bronchiolitis. These patient profiles are generally excluded from bronchiolitis trials, and therefore not specifically covered by the current guideline. Further research should focus on the benefit of bronchiolitis interventions in these particular populations.
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Affiliation(s)
- Laure F Pittet
- Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
- Unit of Pediatric Infectious Diseases, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Alban Glangetas
- Division of Pediatric Emergency, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Constance Barazzone-Argiroffo
- Unit of Pediatric Pulmonology, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Alain Gervaix
- Division of Pediatric Emergency, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Klara M Posfay-Barbe
- Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
- Unit of Pediatric Infectious Diseases, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Annick Galetto-Lacour
- Division of Pediatric Emergency, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Fabiola Stollar
- Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
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Sweetnam C, Goulding L, Davis RE, Khadjesari Z, Boaz A, Healey A, Sevdalis N, Bakolis I, Hull L. Development and psychometric evaluation of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool: a study protocol. BMJ Open 2022; 12:e061209. [PMID: 36526311 PMCID: PMC9764655 DOI: 10.1136/bmjopen-2022-061209] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 09/29/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The need for quantitative criteria to appraise the quality of implementation research has recently been highlighted to improve methodological rigour. The Implementation Science Research development (ImpRes) tool and supplementary guide provide methodological guidance and recommendations on how to design high-quality implementation research. This protocol reports on the development of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool, a quantitative appraisal tool, developed based on the structure and content of the ImpRes tool and supplementary guide, to evaluate the conceptual and methodological quality of implementation research. METHODS AND ANALYSIS This study employs a three-stage sequential mixed-methods design. During stage 1, the research team will map core domains of the ImpRes tool, guidance and recommendations contained in the supplementary guide and within the literature, to ImpResPAC. In stage 2, an international multidisciplinary expert group, recruited through purposive sampling, will inform the refinement of ImpResPAC, including content, scoring system and user instructions. In stage 3, an extensive psychometric evaluation of ImpResPAC, that was created in stage 1 and refined in stage 2, will be conducted. The scaling assumptions (inter-item and item-total correlations), reliability (internal consistency, inter-rater) and validity (construct and convergent validity) will be investigated by applying ImpResPAC to 50 protocols published in Implementation Science. We envisage developing ImpResPAC in this way will provide implementation research stakeholders, primarily grant reviewers and educators, a comprehensive, transparent and fair appraisal of the conceptual and methodological quality of implementation research, increasing the likelihood of funding research that will generate knowledge and contribute to the advancement of the field. ETHICS AND DISSEMINATION This study will involve human participants. This study has been registered and minimal risk ethical clearance granted by The Research Ethics Office, King's College London (reference number MRA-20/21-20807). Participants will receive written information on the study via email and will provide e-consent if they wish to participate. We will use traditional academic modalities of dissemination (eg, conferences and publications).
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Affiliation(s)
- Chloe Sweetnam
- Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lucy Goulding
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - Rachel E Davis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - Zarnie Khadjesari
- Behavioural and Implementation Science Research Group, School of Health Sciences, University of East Anglia, Norwich, UK
| | - Annette Boaz
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Andy Healey
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - Ioannis Bakolis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Louise Hull
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
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Moore JL, Bø E, Erichsen A, Rosseland I, Halvorsen J, Bratlie H, Hornby TG, Nordvik JE. Development and Results of an Implementation Plan for High-Intensity Gait Training. J Neurol Phys Ther 2021; 45:282-291. [PMID: 34369450 PMCID: PMC8423140 DOI: 10.1097/npt.0000000000000364] [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] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND PURPOSE High-intensity gait training is recommended in stroke rehabilitation to improve gait speed, walking distance, and balance. However, identifying effective and efficient implementation methods is a challenge for rehabilitation providers. This article describes the development of an implementation plan, presents findings of each implementation phase, and identifies the project's impact on clinicians and the health system. METHODS Two inpatient rehabilitation facilities, including 9 physical therapists, collaborated with a knowledge translation center to implement this program. We developed an implementation plan using the Knowledge-to-Action Framework and utilized the Consolidated Framework for Implementation Research to identify barriers and select implementation strategies. Using mix-methods research, including surveys and informal discussions, we evaluated current practice, barriers, outcomes, and the sustainability of high-intensity gait training in practice. RESULTS A multicomponent implementation plan that targeted barriers was developed. Before implementation, clinicians reported providing several balance, strength training, and gait interventions to improve walking. Barriers to using high-intensity gait training included knowledge, beliefs, adaptability of high-intensity gait training, resources, culture, and others. Twenty-six implementation strategies were selected to target the barriers. Surveys and informal discussions identified significant changes in perceived practice, adoption of high-intensity gait training, and positive impacts on the health system. The 2-year follow-up survey indicated that the new practice was sustained. DISCUSSION AND CONCLUSIONS Using a multicomponent implementation plan that targeted barriers, we successfully implemented high-intensity gait training in clinical practice. Contributors to successful implementation may include the implementation methods, usual care interventions, and clinicians' readiness for this change.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A352.).
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Affiliation(s)
- Jennifer L. Moore
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - Elisabeth Bø
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - Anne Erichsen
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - Ingvild Rosseland
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - Joakim Halvorsen
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - Hanne Bratlie
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - T. George Hornby
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
| | - Jan Egil Nordvik
- First Oslo team members are as follows: Tonje Barkenæs, Miriam Byhring, Magnus Hågå, Chris Henderson, Mari Klokkerud, Julia Mbalilaki, Stein-Arne Rimehaug, Thomas Tomren, and Karen Vergoossen
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Roczniewska M, von Thiele Schwarz U, Augustsson H, Nilsen P, Ingvarsson S, Hasson H. How do healthcare professionals make decisions concerning low-value care practices? Study protocol of a factorial survey experiment on de-implementation. Implement Sci Commun 2021; 2:50. [PMID: 34011415 PMCID: PMC8136038 DOI: 10.1186/s43058-021-00153-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A large number of practices used in health care lack evidence of effectiveness and may be unnecessary or even cause harm. As such, they should be de-implemented. While there are multiple actors involved in de-implementation of such low-value care (LVC) practices, ultimately, the decision to abandon a practice is often made by each health care professional. A recent scoping review identified 6 types of factors affecting the utilization vs. abandonment of LVC practices. These factors concern health care professionals, patients, outer context, inner context, processes, and the characteristics of LVC practice itself. However, it is unclear how professionals weigh these different factors in and how these determinants influence their decisions about abandoning LVC practices. This project aims to investigate how health care professionals account for various factors as they make decisions regarding de-implementation of LVC practices. METHODS This project will be carried out in two main steps. First, a factorial survey experiment (a vignette study) will be applied to empirically test the relevance of factors previously identified in the literature for health care professionals' decision-making about de-implementation. Second, interactive workshops with relevant stakeholders will be carried out to develop a framework for professionals' decision-making and to offer suggestions for interventions to support de-implementation of LVC practices. DISCUSSION The project has the potential to contribute to improved understanding of the decision-making involved in de-implementation of LVC practices. We will identify which factors are more important when they make judgments about utilizing versus abandoning LVC practices. The results will provide the basis for recommendations concerning appropriate interventions to support de-implementation decision-making processes.
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Affiliation(s)
- Marta Roczniewska
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychology, SWPS University of Social Sciences and Humanities, Sopot, Poland
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Health and Society, Linköping University, Linköping, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden.
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10
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Kenny A, Dickson-Swift V, Chan CKY, Masood M, Gussy M, Christian B, Hodge B, Furness S, Hanson LC, Clune S, Zadow E, Knevel RJ. Oral health interventions for older people in residential aged care facilities: a protocol for a realist systematic review. BMJ Open 2021; 11:e042937. [PMID: 33952539 PMCID: PMC8103368 DOI: 10.1136/bmjopen-2020-042937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Poor oral health among older people is a global problem impacting on health and well-being. The economic cost to the health system is significant. An ageing population is intensifying the urgency for action. However, poor oral health, particularly for those in residential aged care facilities, continues to be highly resistant to resolution. The overall aims of this realist review are to: (A) explore and synthesise evidence on oral health interventions for older people in residential aged care facilities, (B) produce a causal theory on how contextual factors and mechanisms interact to produce outcomes, and (C) produce guidelines/policies to inform high-quality oral health interventions to improve older people's oral health in residential aged care facilities. METHODS AND ANALYSIS The review is guided by the RAMESES publication standards for realist synthesis. Participants include older people in residential aged care facilities, the aged care workforce, carers and families. Interventions include oral healthcare, oral health education, policy interventions and oral health promotion. The five-step realist review process of Pawson et al will guide the review: clarification of scope and development of initial framework, systematic searches, study appraisal and data extraction, synthesising evidence, drawing conclusions, and dissemination, implementation and evaluation. Expert input with key stakeholders will occur through a blog. Stakeholders will examine consistencies across studies and an explanatory causal theory will be developed to guide policy and practice. ETHICS AND DISSEMINATION Formal ethical approval was granted by the La Trobe University Ethics Committee HREC 20144. The developed theory will guide education, practice and policy decisions about interventions and the factors that impact on implementation. Using an integrated knowledge translation approach, traditional research outputs such as international conference presentations and publications will be supplemented with stakeholder forums, infographics, blogs, social media postings, webinars, podcasts and writing for web-based independent outlets. PROSPERO REGISTRATION NUMBER CRD42021155658.
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Affiliation(s)
- Amanda Kenny
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | | | - Carina Ka Yee Chan
- School of Psychology and Public Health, La Trobe University College of Science, Health and Engineering, Bendigo, Victoria, Australia
| | - Mohd Masood
- Department of Dentistry and Oral Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark Gussy
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK
| | - Bradley Christian
- Department of Dentistry and Oral Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Brad Hodge
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Susan Furness
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Lisa C Hanson
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Samantha Clune
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Emma Zadow
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Ron J Knevel
- Department of Dentistry and Oral Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
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11
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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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12
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Wolk CB, Schondelmeyer AC, Barg FK, Beidas R, Bettencourt A, Brady PW, Brent C, Eriksen W, Kinkler G, Landrigan CP, Neergaard R, Bonafide CP. Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis. J Hosp Med 2021; 16:23-30. [PMID: 33357326 PMCID: PMC7768921 DOI: 10.12788/jhm.3535] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms. METHODS This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach. RESULTS Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice. CONCLUSION We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.
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Affiliation(s)
- Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rinad Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda Bettencourt
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Whitney Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Kinkler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rebecca Neergaard
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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