Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials

Patient handling training interventions and musculoskeletal injuries in healthcare workers: Systematic review and meta-analysis

Workplace injuries are a serious issue for the health and social care industry, with the sector accounting for 20 % of all serious claims reported. The aim of this systematic review was to determine whether patient handling training interventions that included instruction on patient transfer techniques are effective in preventing musculoskeletal injuries in healthcare workers. Methods: Electronic databases MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and Health and Safety Science Abstracts (ProQuest) were searched for controlled trials from January 1996-August 2022. Risk of bias was evaluated using the PEDro scale and overall certainty of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluation for each meta-analysis. Results: A total of nine studies (3903 participants) were included. There is moderate certainty evidence that could not conclude whether patient handling training affects the 12-month incidence of lower back pain (OR = 0.83, 95 % CI [0.59, 1.16]). There is low certainty evidence that patient handing training does not prevent lower back pain in health professionals without pre-existing pain (MD = -0.06, 95 % CI [-0.63, 0.52]) but may reduce lower back pain in those with pre-existing pain (MD = -2.92, 95 % CI [-5.44, -0.41]). The results also suggest that there may be a positive effect of training incorporating risk assessment on musculoskeletal injury rates; however the evidence is of very low certainty. There is low certainty evidence from a single study that training may have a short-term effect on sickness absences.) Conclusions: There is a lack of evidence to support patient handling training when delivered to all healthcare staff. Training in its current form may be an ineffective strategy for reducing musculoskeletal injuries and pain. High quality disinvestment studies or trials incorporating risk assessment strategies are warranted. Practical Applications: This review suggests health service managers question the effectiveness of current patient handling training practices and consider evaluating current practices before allocating resources to meet employee risk reduction obligations.

Consumer perspectives of allied health involvement in a public hospital setting: cross-sectional survey and electronic health record review

Objective Consumer-centred care is fundamental to high-quality health care, with allied health professionals playing a pivotal role in hospital settings. Allied health typically operates within standard weekday working-hours. Consumer preferences for receiving allied health services are largely unexplored but could inform whether weekend and/or out-of-hours services are required. This study aims to understand consumer preferences for hospital-based inpatient and outpatient allied health services. Methods Using a cross-sectional survey and convenience sampling approach, consumers of a public health service in Melbourne, Australia were surveyed about preferences for allied health service delivery. Electronic health record reviews compared the accuracy of self-reported service delivery times. Descriptive statistics, concordance and predictive values were calculated. Responses to free-text survey items were analysed using content analysis. Results Of 120 participants (79% response rate), most (69%) received allied health services, however, almost half of inpatient responders (44%) were unsure of the specific allied health professional involved. Audit results found moderate-high concordance overall (range, 77-96%) between self-reported and audit-identified allied health services by profession. Most inpatient responders had no strong day of week preference, equally selecting weekdays and weekend days, with most preferring services between 8 am and 4 pm. Outpatient responders (81%) preferred a weekday appointment between 8 am and 12 pm or before 8 am (29%) to complete scheduled activities early in the day. Conclusion While provision of allied health services during standard working-hours was preferred by most consumers, some inpatient and outpatient consumers are receptive to receiving weekend and out-of-hours services, respectively. Decisions about offering these services should consider operational capacity and research evidence.

Cluster randomized trial designs for modeling time-varying intervention effects

Stepped-wedge cluster randomized trials (SW-CRTs) are typically analyzed assuming a constant intervention effect. In practice, the intervention effect may vary as a function of exposure time, leading to biased results. The estimation of time-on-intervention (TOI) effects specifies separate discrete intervention effects for each elapsed period of exposure time since the intervention was first introduced. It has been demonstrated to produce results with minimum bias and nominal coverage probabilities in the analysis of SW-CRTs. Due to the design's staggered crossover, TOI effect variances are heteroskedastic in a SW-CRT. Accordingly, we hypothesize that alternative CRT designs will be more efficient at modeling certain TOI effects. We derive and compare the variance estimators of TOI effects between a SW-CRT, parallel CRT (P-CRT), parallel CRT with baseline (PB-CRT), and novel parallel CRT with baseline and an all-exposed period (PBAE-CRT). We also prove that the time-averaged TOI effect variance and point estimators are identical to that of the constant intervention effect in both P-CRTs and PB-CRTs. We then use data collected from a hospital disinvestment study to simulate and compare the differences in TOI effect estimates between the different CRT designs. Our results reveal that the SW-CRT has the most efficient estimator for the early TOI effect, whereas the PB-CRT typically has the most efficient estimator for the long-term and time-averaged TOI effects. Overall, the PB-CRT with TOI effects can be a more appropriate choice of CRT design for modeling intervention effects that vary by exposure time.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

"The right thing for our patients": perspectives of physical therapists transitioning to a 7 day a week service in an urban acute care center in Canada

BACKGROUND

True seven day a week acute care physical therapy (PT) coverage is rare. Our facility is one of a few in Canada that has increased weekend PT coverage on medicine units to seven days of full PT staffing levels.

OBJECTIVE

This article investigates the perspectives of physical therapists involved in the change with the focus on the emotional experiences of those therapists.

METHODS

Thematic analysis of interview and focus group transcripts with 18 physical therapist and 2 manager participants were aligned with four themes of: 1) optimism, hope and excitement; 2) frustration, guilt, and resentment; 3) fear, anxiety, uncertainty, and vulnerability; and 4) ambivalence, neutrality, and impartiality.

RESULTS

Although there were several perceived benefits to quality of care and work/life balance, participants' comments also reflected: frustration, guilt, and resentment related to the rapid implementation of the change and the impact of altered work schedules.

CONCLUSIONS

Participants emphasized the need to discuss large changes with staff prior to implementation in order to prevent frustration and resentment. Participants also felt that increased acute care PT coverage over seven days is valuable, but other allied health professions also need a proportional increase in staffing to improve hospital flow.

Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand

BACKGROUND

In Australia and New Zealand, there are currently no recommendations to guide staffing levels for intensive care unit (ICU) physiotherapy services, and there is limited information about the current services provided.

OBJECTIVES

The objective of this study was to document the profile of intensive care physiotherapy services currently offered in Australia and New Zealand.

METHODS

A binational survey was distributed to physiotherapists. The survey sought information on staffing and service profiles for weekday, weekend, and after-hour services including on-call and evening shifts.

RESULTS

Eighty-six sites completed the survey, with responses primarily from Level 3 (47/86, 55%) and public ICUs (74/86, 86%). For weekday services, the ratio of full-time equivalent physiotherapy staff allocated per bed was similar between all intensive care levels (0.11 [0.08-0.15], p = 0.421). Thirty respondents (35%) were satisfied with their staffing and reported higher levels of physiotherapy staff per bed (0.15 [0.1-0.2], p < 0.001). Most sites reported lower levels of staffing for weekend services (76/86, 88%), and many physiotherapists indicated that they were not satisfied with this service (55/86, 64%). Most Level 2, Level 3, and paediatric ICUs had a designated senior physiotherapist, with similar levels of senior physiotherapy staff allocated per bed between all ICU levels (0.05 [0.03-0.08], p = 0.844). Few sites reported dedicated staff attributed to intensive care education, research, tracheostomy service, or outreach roles. On-call physiotherapy services were available in 49 of 86 (57%) hospitals surveyed; however, utilisation of the service by ICUs was mainly reported to be less than once per month (19/49, 39%).

CONCLUSIONS

Physiotherapy staffing ratios were similar across different ICU levels. While weekend services are available for most ICUs, staffing levels are reduced. Higher staffing ratios were associated with higher levels of satisfaction to complete professional roles and responsibilities.

How Can Implementation Science Improve the Care of Familial Hypercholesterolaemia?

PURPOSE OF REVIEW

Describe the application of implementation science to improve the detection and management of familial hypercholesterolaemia.

RECENT FINDINGS

Gaps between evidence and practice, such as underutilization of genetic testing, family cascade testing, failure to achieve LDL-cholesterol goals and low levels of knowledge and awareness, have been identified through clinical registry analyses and clinician surveys. Implementation science theories, models and frameworks have been applied to assess barriers and enablers in the literature specific to local contextual factors (e.g. stages of life). The effect of implementation strategies to overcome these factors has been evaluated; for example, automated identification of individuals with FH or training and education to improve statin adherence. Clinical registries were identified as a key infrastructure to monitor, evaluate and sustain improvements in care. The expansion in evidence supporting the care of familial hypercholesterolaemia requires a similar expansion of efforts to translate new knowledge into clinical practice.

Engaging the consumer in disinvestment in public healthcare: Concerns, perspectives and attitudes of older adults

RATIONALE

Low-value care in public health can be addressed via disinvestment with the support of disinvestment research generated evidence. Consumers' views of disinvestment have rarely been explored despite the potential effects of this process on the care they will receive and the importance of consumer participation in decision-making in public healthcare.

AIMS AND OBJECTIVES

This study aimed to understand consumer concerns, perceptions and attitudes towards disinvestment processes, with the goal of providing recommendations to health service researchers and managers to more effectively engage consumers in shared decision-making in public healthcare.

METHOD

We conducted semistructured interviews using four scenarios describing the principles of disinvestment, how and why it could be undertaken, and a fifth scenario that described a real-life application of these principles. These scenarios were presented to participants in a written word document or a digital story during semistructured interviews. Participants were 18 community-dwelling older adults who were recruited via convenience sampling. Questions were addressed to the participants regarding their feelings and concerns towards disinvestment, their participation as consumers in disinvestment processes, as well as their preference for communicating information about disinvestment to patients and families.

RESULTS

Four major themes emerged around the negative perception of disinvestment and positive perception of research. Participants were concerned that the removal of a clinical activity was mainly the result of financial constraints in hospital systems. At times, participants indicated that disinvestment and its justifications were not easily understood. Participants expressed a need for consumer advocacy not always through themselves, but via others with more expertize; a single consumer is insufficient in representing the broader consumer perspective. Participants stressed the importance of transparency in relation to research evidence and decision-making outcomes. Face-to-face dissemination of information by expert staff was preferred, which could be supplemented with clear and concise written materials.

CONCLUSION

Consumers' main perception of disinvestment processes was that the removal of a clinical care activity depended on financial imperatives from hospital administration and political agendas. This tended to cause suspicion about reasons behind the removal of care, which overshadowed comprehension of the ineffective/inconclusive evidence that were key to disinvestment.

Analysis of stepped wedge cluster randomized trials in the presence of a time-varying treatment effect

Stepped wedge cluster randomized controlled trials are typically analyzed using models that assume the full effect of the treatment is achieved instantaneously. We provide an analytical framework for scenarios in which the treatment effect varies as a function of exposure time (time since the start of treatment) and define the "effect curve" as the magnitude of the treatment effect on the linear predictor scale as a function of exposure time. The "time-averaged treatment effect" (TATE) and "long-term treatment effect" (LTE) are summaries of this curve. We analytically derive the expectation of the estimatorδ ^ $$ \hat{\delta} $$ resulting from a model that assumes an immediate treatment effect and show that it can be expressed as a weighted sum of the time-specific treatment effects corresponding to the observed exposure times. Surprisingly, although the weights sum to one, some of the weights can be negative. This implies thatδ ^ $$ \hat{\delta} $$ may be severely misleading and can even converge to a value of the opposite sign of the true TATE or LTE. We describe several models, some of which make assumptions about the shape of the effect curve, that can be used to simultaneously estimate the entire effect curve, the TATE, and the LTE. We evaluate these models in a simulation study to examine the operating characteristics of the resulting estimators and apply them to two real datasets.

Hospital Access Block: A Scoping Review

INTRODUCTION

The overarching objective of this scoping review was to explore the breadth of health care literature in attempts to identify current strategies that hospitals adopt to improve patient bed flow, reduce access and exit block while optimizing patient care.

METHODS

PubMed, CINAHL, Embase, Proquest, and Cochrane electronic library databases supported literature search in March 2021. Scholarly articles that met the 3 eligibility criteria-access block causes, effects, and solutions-were considered. Joanna Briggs Institute Guidelines supported first- and second-level literary screening processes.

RESULTS

The synthesis included 43 references. Most initiatives addressed access (n = 15), followed by care (n = 16) and then community (n = 9), with a further 3 articles providing commentary across all 3 domains (n = 3). Evidence supported Lean principles in both emergency department and inpatient sector. Lean principles addressing access included physician-led ED triage models, point-of-care testing, overcapacity protocols, mental health team collocation models, and fast-track services. Inpatient care Lean concepts validated gains in multidisciplinary rounds, appropriate allocation of allied health services with a 7-days-a-week model, staggering of elective surgeries, journey boards usage, transit lounges, and lateral transfers. Most literature addressing the backend was narrative in nature, theorized, and advocating for solutions and policy reform.

DISCUSSION

This study addressed aims and identified current strategies that hospitals adopt to tackle access block while guaranteeing patient care. Government-supported research to map out evidence-based models of care that address exit block and demonstrate efficiencies is required to optimize access to care in the community.

Use of information criteria for selecting a correlation structure for longitudinal cluster randomised trials

BACKGROUND

When designing and analysing longitudinal cluster randomised trials, such as the stepped wedge, the similarity of outcomes from the same cluster must be accounted for through the choice of a form for the within-cluster correlation structure. Several choices for this structure are commonly considered for application within the linear mixed model paradigm. The first assumes a constant intra-cluster correlation for all pairs of outcomes from the same cluster (the exchangeable/Hussey and Hughes model); the second assumes that correlations of outcomes measured in the same period are higher than outcomes measured in different periods (the block exchangeable model) and the third is the discrete-time decay model, which allows the correlation between pairs of outcomes to decay over time. Currently, there is limited guidance on how to select the most appropriate within-cluster correlation structure.

METHODS

We simulated continuous outcomes under each of the three considered within-cluster correlation structures for a range of design and parameter choices, and, using the ASReml-R package, fit each linear mixed model to each simulated dataset. We evaluated the performance of the Akaike and Bayesian information criteria for selecting the correct within-cluster correlation structure for each dataset.

RESULTS

For smaller total sample sizes, neither criteria performs particularly well in selecting the correct within-cluster correlation structure, with the simpler exchangeable model being favoured. Furthermore, in general, the Bayesian information criterion favours the exchangeable model. When the cluster auto-correlation (which defines the degree of dependence between observations in adjacent time periods) is large and number of periods is small, neither criteria is able to distinguish between the block exchangeable and discrete time decay models. However, for increasing numbers of clusters, periods, and subjects per cluster period, both the Akaike and Bayesian information criteria perform increasingly well in the detection of the correct within-cluster correlation structure.

CONCLUSIONS

With increasing amounts of data, be they number of clusters, periods or subjects per cluster period, both the Akaike and Bayesian information criteria are increasingly likely to select the correct correlation structure. We recommend that if there are sufficient data available when planning a trial, that the Akaike or Bayesian information criterion is used to guide the choice of within-cluster correlation structure in the absence of other compelling justifications for a specific correlation structure. We also suggest that researchers conduct supplementary analyses under alternate correlation structures to gauge sensitivity to the initial choice.

Development and delivery of an allied health team intervention for older adults in the emergency department: A process evaluation

Background

There is encouraging evidence that interdisciplinary teams of Health and Social Care Professionals (HSCPs) can enhance patient care in the Emergency Department (ED), especially for older adults with complex needs. However, no formal process evaluations of implementations of ED-based HSCP interventions are available. The study aimed to evaluate the development and delivery of a HSCP team intervention for older adults in the ED of a large Irish teaching hospital.

Methods

Using the Medical Research Council (MRC) Framework for process evaluations, we investigated implementation and delivery, mechanisms of impact, and contextual influences on implementation by analysing the HSCP team’s activity notes and participant recruitment logs, and by carrying out six interviews and four focus groups with 26 participants (HSCP team members, ED doctors and nurses, hospital staff). Qualitative insights were analysed thematically.

Results

The implementation process had three phases (pre-implementation, piloting, and delivery), with the first two described as pivotal to optimise care procedures and build positive stakeholders’ involvement. The team’s motivation and proactive communication were key to promote acceptability and integration in the ED (Theme 1); also, their specialised skills and interdisciplinary approach enhanced patient and staff’s ED experience (Theme 2). The investment and collaboration of multiple stakeholders were described as essential contextual enablers of implementation (Theme 4). Delivering the intervention within a randomised controlled trial fostered credibility but caused frustration among patients and staff (Theme 3).

Discussion

This process evaluation is the first to provide in-depth and practical insights on the complexities of developing and delivering an ED-based HSCP team intervention for older adults. Our findings highlight the importance of establishing a team of HSCPs with a strong interdisciplinary ethos to ensure buy-in and integration in the ED processes. Also, actively involving relevant stakeholders is key to facilitate implementation.

Trial registration

ClinicalTrials.gov, NCT03739515; registered on 12^th November 2018.

Model misspecification in stepped wedge trials: Random effects for time or treatment

Mixed models are commonly used to analyze stepped wedge trials (SWTs) to account for clustering and repeated measures on clusters. One critical issue researchers face is whether to include a random time effect or a random treatment effect. When the wrong model is chosen, inference on the treatment effect may be invalid. We explore asymptotic and finite-sample convergence of variance component estimates when the model is misspecified and how misspecification affects the estimated variance of the treatment effect. For asymptotic results, we rely on analytical solutions rather than simulation studies, which allow us to succinctly describe the convergence of misspecified estimates, even though there are multiple roots for each misspecified model. We found that both direction and magnitude of the bias associated with model-based standard errors depends on the study design and magnitude of the true variance components. We identify some scenarios in which choosing the wrong random effect has a large impact on model-based inference. However, many trends depend on trial design and assumptions about the true correlation structure, so we provide tools for researchers to investigate specific scenarios of interest. We use data from an SWT on disinvesting from weekend services in hospital wards to demonstrate how these results can be applied as a sensitivity analysis, which quantifies the impact of misspecification under a variety of settings and directly compares the potential consequences of different modeling choices. Our results will provide guidance for prespecified model choices and supplement sensitivity analyses to inform confidence in the validity of results.

Effectiveness of Hospital-Based Interventions by Occupational Therapy Practitioners on Reducing Readmissions: A Systematic Review With Meta-Analyses

IMPORTANCE

Readmission to the hospital can lead to poorer patient outcomes and increased health care costs. The effect of occupational therapy interventions for adult hospitalized patients on readmission rates has not been previously evaluated.

OBJECTIVE

To systematically examine the published literature to determine the effects of occupational therapy interventions for adult hospitalized patients on readmission rates.

DATA SOURCES

Systematic search of five electronic databases was performed from database inception until May 2020, supplemented by citation and reference list searches. Study Selection and Data Collection: This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively; methodological quality of the included studies was assessed using the Downs and Black checklist. Meta-analyses were conducted with clinically homogeneous data; the overall body of evidence was graded for quality.

FINDINGS

Meta-analysis of 7 studies with 16,718 participants provided low-quality evidence that 1-mo readmission rates were reduced when adult patients hospitalized for general medical and surgical care received additional occupational therapy interventions compared with standard care. Subgroup analysis of 4 studies provided moderate-quality evidence that interventions focusing on the transition from hospital to the community were effective in reducing 1-mo readmissions to hospitals compared with standard care.

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions can be effective in reducing readmissions among some adult hospitalized patient populations, including those admitted for surgery or management of acute medical conditions, with stronger evidence to support transitional care interventions. What This Article Adds: Occupational therapy interventions can be effective in reducing readmissions among adult hospitalized patients. There is a continued need for occupational therapy practitioners to understand their value and contribution to reducing avoidable readmissions to hospitals.

Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

BACKGROUND

Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.

METHODS AND FINDINGS

This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control β -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.

CONCLUSIONS

Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Inference for the treatment effect in longitudinal cluster randomized trials when treatment effect heterogeneity is ignored

In cluster-randomized trials, sometimes the effect of the intervention being studied differs between clusters, commonly referred to as treatment effect heterogeneity. In the analysis of stepped wedge and cluster-randomized crossover trials, it is possible to include terms in outcome regression models to allow for such treatment effect heterogeneity yet this is not frequently considered. Outside of some simulation studies of specific cases where the outcome is binary, the impact of failing to include terms for treatment effect heterogeneity on the variance of the treatment effect estimator is unknown. We analytically examine the impact of failing to include terms for treatment effect heterogeneity on the variance of the treatment effect estimator, when outcomes are continuous. Using analysis of variance and feasible generalized least squares we provide expressions for this variance. For both the cluster-randomized crossover design and the stepped wedge design, our analytic derivations indicate that failing to include treatment effect heterogeneity results in the estimates for variance of the treatment effect that are too small, leading to inflation of type I error rates. We therefore recommend assessing the sensitivity of sample size calculations and conclusions drawn from the analysis of cluster randomized trials to the inclusion of treatment effect heterogeneity.

Variation in inpatient allied health service provision in Australian and New Zealand hospitals

OBJECTIVE

To describe the variability of allied health services on weekends, relative to weekdays, throughout Australian and New Zealand hospitals.

METHODS

A prospective, cross-sectional observational study embedded within a cluster randomised control trial. Allied health managers provided administrative data relating to allied health service events.

RESULTS

In one month, there were a total of 243 549 allied health service events recorded from 91 sampled hospitals. The mean difference between weekday and weekend allied health service events (daily, per ward) for physiotherapy was 6.52 (95% CI 5.65 to 7.40), acute wards 12.03 (95% CI 10.25 to 13.82) and for metropolitan hospitals 14.47 (95% CI 12.22 to 16.73), revealing more allied health service events of longer duration on weekdays compared to weekends.

CONCLUSIONS

This research is the first of its kind to describe variation in allied health service provision and potential research to practice gaps across weekday and weekend days in various inpatient settings.

Virtual communities of practice to improve clinical outcomes in healthcare: protocol for a 10-year scoping review

INTRODUCTION

Virtual communities of practice (VCoPs) use a common online platform to provide healthcare professionals with the opportunity to access highly specialised knowledge, build a professional support network and promote the translation of research evidence into practice. There is limited reporting of how best to design and administer VCoPs within healthcare organisations. The primary aim of this scoping review is to identify the best methods used to establish and maintain VCoPs. Findings shall be used to develop a flexible framework to guide the establishment and facilitation of a VCoP for healthcare professionals to ensure the translation of falls prevention clinical guidelines into practice.

METHODS AND ANALYSIS

A five-stage scoping review process will be followed based on Arksey and O'Malley's framework and refined by the Joanna Briggs Institute Methodology. An initial limited search of PubMed and Cumulative Index to Nursing and Allied Health Literature will identify relevant studies and assist with search term development. This will be followed by a search of five online databases to identify papers published from January 2010 until November 2020. Papers will be independently screened by two reviewers, and data extracted and analysed using a reporting framework. Qualitative data will be analysed thematically and numerical synthesis of the data will be conducted.

RESULTS AND DISSEMINATION

The results of this scoping review will highlight the best ways to design and manage VCoPs in healthcare organisations. The findings will be presented at relevant stakeholder workshops, conferences and published in peer-reviewed journals.

Intra-cluster correlations from the CLustered OUtcome Dataset bank to inform the design of longitudinal cluster trials

BACKGROUND

Sample size calculations for longitudinal cluster randomised trials, such as crossover and stepped-wedge trials, require estimates of the assumed correlation structure. This includes both within-period intra-cluster correlations, which importantly differ from conventional intra-cluster correlations by their dependence on period, and also cluster autocorrelation coefficients to model correlation decay. There are limited resources to inform these estimates. In this article, we provide a repository of correlation estimates from a bank of real-world clustered datasets. These are provided under several assumed correlation structures, namely exchangeable, block-exchangeable and discrete-time decay correlation structures.

METHODS

Longitudinal studies with clustered outcomes were collected to form the CLustered OUtcome Dataset bank. Forty-four available continuous outcomes from 29 datasets were obtained and analysed using each correlation structure. Patterns of within-period intra-cluster correlation coefficient and cluster autocorrelation coefficients were explored by study characteristics.

RESULTS

The median within-period intra-cluster correlation coefficient for the discrete-time decay model was 0.05 (interquartile range: 0.02-0.09) with a median cluster autocorrelation of 0.73 (interquartile range: 0.19-0.91). The within-period intra-cluster correlation coefficients were similar for the exchangeable, block-exchangeable and discrete-time decay correlation structures. Within-period intra-cluster correlation coefficients and cluster autocorrelations were found to vary with the number of participants per cluster-period, the period-length, type of cluster (primary care, secondary care, community or school) and country income status (high-income country or low- and middle-income country). The within-period intra-cluster correlation coefficients tended to decrease with increasing period-length and slightly decrease with increasing cluster-period sizes, while the cluster autocorrelations tended to move closer to 1 with increasing cluster-period size. Using the CLustered OUtcome Dataset bank, an RShiny app has been developed for determining plausible values of correlation coefficients for use in sample size calculations.

DISCUSSION

This study provides a repository of intra-cluster correlations and cluster autocorrelations for longitudinal cluster trials. This can help inform sample size calculations for future longitudinal cluster randomised trials.

Applying a framework to assess the impact of cardiovascular outcomes improvement research

Background

Health and medical research funding agencies are increasingly interested in measuring the impact of funded research. We present a research impact case study for the first four years of an Australian National Health and Medical Research Council funded Centre of Research Excellence in Cardiovascular Outcomes Improvement (2016–2020). The primary aim of this paper was to explore the application of a research impact matrix to assess the impact of cardiovascular outcomes improvement research.

Methods

We applied a research impact matrix developed from a systematic review of existing methodological frameworks used to measure research impact. This impact matrix was used as a bespoke tool to identify and understand various research impacts over different time frames. Data sources included a review of existing internal documentation from the research centre and publicly available information sources, informal iterative discussions with 10 centre investigators, and confirmation of information from centre grant and scholarship recipients.

Results

By July 2019, the impact on the short-term research domain category included over 41 direct publications, which were cited over 87 times (median journal impact factor of 2.84). There were over 61 conference presentations, seven PhD candidacies, five new academic collaborations, and six new database linkages conducted. The impact on the mid-term research domain category involved contributions towards the development of a national cardiac registry, cardiovascular guidelines, application for a Medicare Benefits Schedule reimbursement item number, introduction of patient-reported outcome measures into several databases, and the establishment of nine new industry collaborations. Evidence of long-term impacts were described as the development and use of contemporary management for aortic stenosis, a cardiovascular risk prediction model and prevention targets in several data registries, and the establishment of cost-effectiveness for stenting compared to surgery.

Conclusions

We considered the research impact matrix a feasible tool to identify evidence of academic and policy impact in the short- to midterm; however, we experienced challenges in capturing long-term impacts. Cost containment and broader economic impacts represented another difficult area of impact to measure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00710-4.

Feasibility and adherence to moderate intensity cardiovascular fitness training following stroke: a pilot randomized controlled trial

BACKGROUND

Stroke is a leading cause of disability worldwide and the cardiovascular fitness levels of stroke survivors are diminished to an extent that impairs functioning and activities of daily living performance. While cardiovascular training seems an empirically appropriate intervention, the optimal dosage and intensity of cardiovascular training in stroke survivors remains unclear. The aim was to determine the safety and feasibility of moderate-intensity cardiovascular training following stroke, including measurement of adherence to training.

METHODS

A pilot, prospective, patient- and assessor-blinded randomised controlled trial conducted in a tertiary, metropolitan hospital-based community rehabilitation centre. Eligibility criteria included ambulant (> 100 m), 6 weeks-12 months post stroke. Moderate-intensity fitness training or control (low-intensity) exercise was offered biweekly for 12 weeks. Outcome measures included adverse events, peak oxygen uptake (VO₂), functional exercise capacity (6-Minute Walk Test, 10-m Walk Test) and health-related quality of life (Short Form-36) and mood (Patient Health Questionnaire, PHQ9).

RESULTS

Feasibility: Seventy-one (50%) of 141 screened participants were eligible (29% did not agree to participate). Twenty participants (10 intervention, 10 control) were recruited. The median (%; IQR) supervised sessions was 19.5 (81%; 12, 20); and 20 (83%; 19, 22) in the intervention and control groups, respectively. Progression of duration and intensity was limited; mean of 10 sessions to achieve target duration (30 min). There were no adverse events. Baseline peak oxygen uptake (VO₂) levels were low (15.94 ml/kg/min). Significant improvements in VO₂ peak in both groups were observed (p < 0.05). Although there were no significant between-group differences, this feasibility trial was not powered to detect change.

CONCLUSIONS

Moderate-intensity fitness training was safe but achievement of target duration and intensity was challenging for stroke survivors. A definitive adequately-powered randomised trial is required. Alternative fitness training protocols may need to be explored.

TRIAL REGISTRATION

The trial protocol was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN 12613000822785 ) on 25/07/2013.

Translating evidence into practice: a longitudinal qualitative exploration of allied health decision-making

Background

Health policy and management decisions rarely reflect research evidence. As part of a broader randomized controlled study exploring implementation science strategies we examined how allied health managers respond to two distinct recommendations and the evidence that supports them.

Methods

A qualitative study nested in a larger randomized controlled trial. Allied health managers across Australia and New Zealand who were responsible for weekend allied health resource allocation decisions towards the provision of inpatient service to acute general medical and surgical wards, and subacute rehabilitation wards were eligible for inclusion. Consenting participants were randomized to (1) control group or (2) implementation group 1, which received an evidence-based policy recommendation document guiding weekend allied health resource allocation decisions, or (3) implementation group 2, which received the same policy recommendation document guiding weekend allied health resource allocation decisions with support from a knowledge broker. As part of the trial, serial focus groups were conducted with a sample of over 80 allied health managers recruited to implementation group 2 only. A total 17 health services participated in serial focus groups according to their allocated randomization wave, over a 12-month study period. The primary outcome was participant perceptions and data were analysed using an inductive thematic approach with constant comparison. Thematic saturation was achieved.

Results

Five key themes emerged: (1) Local data is more influential than external evidence; (2) How good is the evidence and does it apply to us? (3) It is difficult to change things; (4) Historically that is how we have done things; and (5) What if we get complaints?

Conclusions

This study explored implementation of strategies to bridge gaps in evidence-informed decision-making. Results provide insight into barriers, which prevent the implementation of evidence-based practice from fully and successfully occurring, such as attitudes towards evidence, limited skills in critical appraisal, and lack of authority to promote change. In addition, strategies are needed to manage the risk of confirmation biases in decision-making processes.

Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12618000029291). Universal Trial Number (UTN): U1111-1205-2621.

Impact of weekend admission and changes in treating team on patient flow and outcomes in adults admitted to hospital with community-acquired pneumonia

BACKGROUND

The effect of workflow factors, such as timing of admission and changes in treating team, on patient outcomes remains inconclusive.

AIMS

To investigate the impact of weekend admission and changes in treating team on four pre-defined outcomes in patients admitted to hospital with community-acquired pneumonia (CAP).

METHODS

We performed an observational cohort study by utilising prospective longitudinal data collected during the IMPROVE-GAP trial, a stepped-wedge randomised study investigating an evidence-based bundle of care in the management of CAP. We assessed the effect of two exposure variables, day of admission and change of treating team, on four pre-specified outcomes: (i) length of stay; (ii) time to clinical stability; (iii) readmission within 30 days; and (iv) mortality at 30 days. Our analysis was restricted to patients with a primary diagnosis of CAP and employed multivariable Cox regression and logistic regression to adjust for potential measured confounders.

RESULTS

Of 753 participants, 224 (29.7%) were admitted on the weekend and 71 (9.4%) changed treating team during admission. Weekend admissions had significantly longer hospital stays than weekday admissions (hazard ratio (95% confidence interval; P-value) 0.82 (0.70-0.98; 0.03)) and took longer to reach clinical stability (0.80 (0.68-0.95; 0.01)). Change of treating team doubled the odds of readmission at 30 days (odds ratio 1.95 (1.08-3.58; 0.03)).

CONCLUSIONS

These results suggest workflow factors can negatively impact both health service and patient outcomes. Systems interventions aimed at improving out of hours service and reducing changes in treating team should be considered.

Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis

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.

Moving Past the Loss: A Longitudinal Qualitative Study of Health Care Staff Experiences of Disinvestment

This longitudinal qualitative study examines staff experience of disinvestment from a service they are accustomed to providing to their patients. It took place alongside a disinvestment trial that measured the impact of the removal of weekend allied health services from acute wards at two hospitals. Data were gathered from repeated interviews and focus groups with 450 health care staff. We developed a grounded theory, which explains changes in staff perceptions over time and the key modifying factors. Staff appeared to experience disinvestment as loss; a key difference to other operational changes. Early staff experiences of disinvestment were primarily negative, but evolved with time and change-management strategies such as the provision of data, clear and persistent communication approaches, and forums where the big picture context of the disinvestment was robustly discussed. These allowed the disinvestment trial to be successfully implemented at two health services, with high compliance with the research protocol.

The effect of transferring weekend physical therapy services from the acute to sub-acute setting in patients following hip and knee arthroplasty: a quasi-experimental study

BACKGROUND

Weekend physical therapy services in the acute and/or sub-acute setting may optimize postoperative recovery following hip and knee arthroplasty, though evidence supporting these services is limited.

PURPOSE

To explore the change in patient and service outcomes of transferring a weekend physical therapy service from the acute to the sub-acute setting following hip and knee arthroplasty.

METHODS

This was a quasi-experimental research design nested within two stepped-wedge cluster randomized controlled trials. Acute weekend physical therapy services were sequentially discontinued and reallocated to the sub-acute setting in a random order from one ward at a time within the broader trial. Patient and service outcomes for participants 6 weeks following hip and knee arthroplasty (N = 247) were compared during 6 months of acute weekend physical therapy services (Phase 1, n = 117) followed by 6 months of sub-acute services (Phase 2, n = 130). Intention-to-treat statistical analyses were conducted.

RESULTS

The intervention had a negligible effect on medium-term outcomes. The only statistically significant difference observed was slightly higher ratings of "worst pain experienced over the past week" [coefficient 0.865 (0.123 to 1.606), p = .022] during Phase 2. No interaction effects were observed despite a 2.4-day reduction in length of stay amongst complex patients during Phase 2 (18.28 and 15.86 days in Phase 1 and 2, respectively).

CONCLUSIONS

No comparative advantage or disadvantage was observed by reallocating a weekend physical therapy budget from the acute to sub-acute setting following hip and knee arthroplasty. Further research investigating the cost-effectiveness of these services in the sub-acute setting may be warranted for complex patients.

The effect of delegation of therapy to allied health assistants on patient and organisational outcomes: a systematic review and meta-analysis

Background

Allied health assistants (AHAs) are support staff who complete clinical and non-clinical tasks under the supervision and delegation of an allied health professional. The effect of allied health professional delegation of clinical tasks to AHAs on patient and healthcare organisational outcomes is unknown. The purpose of this systematic review was to investigate the effect of allied health professional delegation of therapy to AHAs on patient and organisational outcomes.

Methods

A systematic review and meta-analysis was conducted. Databases MEDLINE (Ovid), Embase (Ovid), Informit (all databases), Emcare (Ovid), PsycINFO (Ovid), Cumulative Index to Nursing and Allied Health Literature [CINAHL] (EbscoHost) and the Cochrane Database of Systematic Reviews were searched from earliest date available. Additional studies were identified by searching reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. The quality of the study was rated using internal validity items from the Downs and Black checklist. Risk ratios (RR) and mean differences (MD) were calculated for patient and organisational outcomes. Meta-analyses were conducted using the inverse variance method and random-effects model.

Results

Twenty-two studies met the inclusion criteria. Results of meta-analysis provided low quality evidence that AHA supervised exercise in addition to usual care improved the likelihood of patients discharging home (RR 1.28, 95%CI 1.03 to 1.59, I² = 60%) and reduced length of stay (MD 0.28 days, 95%CI 0.03 to 0.54, I² = 0%) in an acute hospital setting. There was preliminary evidence from one high quality randomised controlled trial that AHA provision of nutritional supplements and assistance with feeding reduced the risk of patient mortality after hip fracture (RR 0.41, 95%CI 0.16 to 1.00). In a small number of studies (n = 6) there was no significant difference in patient and organisational outcomes when AHA therapy was substituted for therapy delivered by an allied health professional.

Conclusion

We found preliminary evidence to suggest that the use of AHAs to provide additional therapy may be effective for improving some patient and organisational outcomes.

Review registration

CRD42019127449.

Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: A systematic review

BACKGROUND

Dedicated Health and Social Care Professional (HSCP) teams have been proposed for emergency departments (EDs) in an effort to improve patient and process outcomes. This systematic review synthesises the totality of evidence relating to the impact of early assessment and intervention by HSCP teams on quality, safety and effectiveness of care in the ED.

METHODS

A systematic literature search was conducted in April 2019 to identify experimental studies examining the effectiveness of ED-based HSCP teams providing services to adults aged ≥ 18 years old and including two or more of the following disciplines: occupational therapist, physiotherapist, medical social worker, clinical pharmacist, or speech and language therapist. Data extraction and quality appraisal of each study were conducted independently by two reviewers.

RESULTS

Six studies were included in the review (n = 273,886), all describing interdisciplinary Care Coordination Teams (CCTs) caring for adults aged ≥ 65 years old. CCT care was associated with on average 2% reduced rates of hospital admissions (three studies), improved referrals to community services for falls (one study), increased satisfaction (two studies) with the safety of discharge (patients and staff), and with the distribution of workload (staff), improved health-related quality of care (one study). No statistically significant differences between intervention and control groups emerged in terms of rates of ED re-visits, ranging between 0.2% and 3% (two studies); hospital length of stay (one hour difference noted in one study) or mortality rates (0.5% difference in one study). Increased rates of unplanned hospitalisations following the intervention (13.9% difference) were reported in one study. The methodological quality of the studies was mixed.

DISCUSSION

We found limited and heterogeneous evidence on the impact of HSCP teams in the ED, suggesting a reduction in hospital admissions as well as improved patient and staff satisfaction. More robust investigations including cost-effectiveness evaluations are needed.

Understanding Health Professional Responses to Service Disinvestment: A Qualitative Study

Background: Disinvestment from inefficient health services may be a potential solution to rising healthcare costs, but there has been poor uptake of disinvestment recommendations. This Australian study aims to understand how health professionals react when confronted with a plan to disinvest from a health service they previously provided to their patients.

Methods: This qualitative study took place prior to the disinvestment phase of a trial which removed weekend allied health services from acute hospital wards, to evaluate the effectiveness and cost effectiveness of the service. Observations and focus groups were used to collect data from 156 participants which was analysed thematically.

Results: Initial reactions to the disinvestment were almost universally negative, with staff extremely concerned about the impact on the safety and quality of patient care and planning ways to circumvent the trial. Removal of existing services was perceived as a loss and created a direct threat to some clinicians’ professional identity. With time, discussion, and understanding of the project’s context, some staff moved towards acceptance and perceived the trial as an opportunity, particularly given the service was to be reinstated after the disinvestment.

Conclusion: Clinicians and health service managers are protective of the services they deliver and can create barriers to disinvestment. Even when services are removed to ascertain their value, health professionals may continue to provide services to their patients. Measuring the impact of the disinvestment may assist staff to accept the removal of a service.

A novel counterbalanced implementation study design: methodological description and application to implementation research

Background

Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy.

Methods

In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition.

Results

An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of ‘video-based’ and ‘written-based’ evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts.

Conclusion

A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0896-0) contains supplementary material, which is available to authorized users.

Costs will rather increase

Purpose

The purpose of this paper was to study the unfolding of an urgent and extensive decommissioning program in Sweden, focusing on the public’s reactions and their arguments when opposing the decommissioning activities.

Design/methodology/approach

The public’s responses were studied through local media. Its content was surveyed and divided into actions and arguments. The arguments were further analyzed and categorized into inductively developed themes.

Findings

Protest activities, such as demonstrations, meetings and petitions, were not coordinated, but mostly carried out for withdrawals of unique services and services in remote areas. The public questioned the decision makers’ information, calculations and competence, the adequacy of the consequence analyses and whether the decommissioning activities would lead to any real savings. Patient and public safety, the vulnerable in society, and effects on the local areas were important topics. Thus, it seems the decision makers did not fully succeed in communicating the demonstrable benefits or create clarity of the rationales for decommissioning the particular services. Furthermore, it seems the public has a more inclusive approach to health services and their value compared to decision makers that need to keep the budget.

Originality/value

Decommissioning is an emerging field of research, and this study of the unfolding of an urgent and extensive decommissioning program contributes with evidence that may improve decommissioning policy and practice. The study illustrates that it may be possible to implement a decommissioning program despite public protest, but that the longer-term effects on the health system’s legitimacy need to be studied.

Health professionals' perceptions of the allied health role in the acute setting following hip and knee joint replacement surgery: a qualitative study

Purpose: To describe health professionals' perceptions of the role of allied health during the acute phase following elective lower limb joint replacement surgery to inform the development of efficient allied health service models.Methods: This was a qualitative descriptive study conducted using semi-structured focus groups and thematic analysis. Participants were 25 medical, nursing, and allied health professionals working on two orthopaedic wards in a tertiary hospital in Victoria, Australia. Focus groups elicited staff perceptions regarding the aims and roles of acute allied health intervention following hip and knee replacement, how these services are currently provided, and how these services can best be provided. This study was undertaken alongside two stepped wedge cluster randomised controlled trials during which existing weekend allied health services were to be temporarily removed with opportunity to contribute to a stakeholder-driven model of these services.Results: The main theme that emerged was a sense of unrealised potential amongst health professionals in terms of patient outcomes following hip and knee joint replacement surgery arising from tension between perceptions of actual versus ideal allied health practice. Assessing function and planning for discharge accordingly was perceived to be a higher priority than intervening to improve functional independence.Conclusion: Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in patients following lower limb replacement surgery than current practice in this setting that prioritises discharge.Implications for RehabilitationAllied health service delivery in the acute phase following hip and knee joint replacement needs to balance the needs of the health service with those of the patients.Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in this population than current practice, which is to prioritise discharge.There may be more scope for nurses to be involved in promoting early postoperative mobilisation following joint replacement surgery, especially in uncomplicated cases.

Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review

QUESTION

Are additional weekend allied health services effective and cost-effective for acute general medical and surgical wards, and subacute rehabilitation hospital wards?

DESIGN

Systematic review and meta-analysis of studies published between January 2000 and May 2017. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality. Meta-analyses were conducted for relative measures of effect estimates.

PARTICIPANTS

Patients admitted to acute general medical and surgical wards, and subacute rehabilitation wards.

INTERVENTION

All services delivered by allied health professionals during weekends (Saturday and/or Sunday). This study limited allied health professions to: occupational therapy, physiotherapy, social work, speech pathology, dietetics, art therapy, chiropractic, exercise physiology, music therapy, oral health (not dentistry), osteopathy, podiatry, psychology, and allied health assistants.

OUTCOME MEASURES

Hospital length of stay, hospital re-admission, adverse events, discharge destination, functional independence, health-related quality of life, and cost of hospital care.

RESULTS

Nineteen articles (20 studies) were identified, comprising 10 randomised and 10 non-randomised trials. Physiotherapy was the most commonly investigated profession. A meta-analysis of randomised, controlled trials showed that providing additional weekend allied health services in subacute rehabilitation wards reduced hospital length of stay by 2.35days (95% CI 0.45 to 4.24, I²=0%), and may be a cost-effective way to improve function (SMD 0.09, 95% CI -0.01 to 0.19, I²=0%), and health-related quality of life (SMD 0.10, 95% CI -0.01 to 0.20, I²=0%). For acute general medical and surgical hospital wards, it was unclear whether the weekend allied health service model provided in the two identified randomised trials led to significant changes in measured outcomes.

CONCLUSION

The benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.

REGISTRATION

PROSPERO CRD76771. [Sarkies MN, White J, Henderson K, Haas R, Bowles J, Evidence Translation in Allied Health (EviTAH) Group (2018) Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review. Journal of Physiotherapy 64: 142-158].

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol

BACKGROUND

It is widely acknowledged that health policy and practice do not always reflect current research evidence. Whether knowledge transfer from research to practice is more successful when specific implementation approaches are used remains unclear. A model to assist engagement of allied health managers and clinicians with research implementation could involve disseminating evidence-based policy recommendations, along with the use of knowledge brokers. We developed such a model to aid decision-making for the provision of weekend allied health services. This protocol outlines the design and methods for a multi-centre cluster randomised controlled trial to evaluate the success of research implementation strategies to promote evidence-informed weekend allied health resource allocation decisions, especially in hospital managers.

METHODS

This multi-centre study will be a three-group parallel cluster randomised controlled trial. Allied health managers from Australian and New Zealand hospitals will be randomised to receive either (1) an evidence-based policy recommendation document to guide weekend allied health resource allocation decisions, (2) the same policy recommendation document with support from a knowledge broker to help implement weekend allied health policy recommendations, or (3) a usual practice control group. The primary outcome will be alignment of weekend allied health service provision with policy recommendations. This will be measured by the number of allied health service events (occasions of service) occurring on weekends as a proportion of total allied health service events for the relevant hospital wards at baseline and 12-month follow-up.

DISCUSSION

Evidence-based policy recommendation documents communicate key research findings in an accessible format. This comparatively low-cost research implementation strategy could be combined with using a knowledge broker to work collaboratively with decision-makers to promote knowledge transfer. The results will assist managers to make decisions on resource allocation, based on evidence. More generally, the findings will inform the development of an allied health model for translating research into practice.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12618000029291 ). Universal Trial Number (UTN): U1111-1205-2621.

Decommissioning care: The need for rigorous multifaceted evaluations of decisions to withdraw health services

In this Perspective on the two clinical trials of Terry Haines and colleagues that incrementally removed and reinstated allied healthcare services, Aziz Sheikh discusses the evidence base for the routine provision of such services.