Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial

Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention

Background

Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa.

Objectives

Co-design a quality improvement intervention for AMI care tailored to local contextual factors.

Methods

An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context.

Findings

The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education.

Conclusion

MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.

Dynamic social network analysis of a brief alcohol intervention trial in heavy-drinking college students shows spillover effects

BACKGROUND

Heavy-drinking college students tend to have close social networks, and there is theoretical and empirical support for the idea that behavior change can spread through those networks via close ties. The objective of this research was to determine whether intervention-induced behavior change in a subset of heavy drinkers in a sociometric (whole) college class-year social network is transmitted to other heavy drinkers in the network, resulting in reduced behavioral risk and change in network ties.

METHODS

We conducted a controlled trial in which most of a first-year college class (N = 1236; 56.9% female) was enrolled, with alcohol use and social network ties measured early in each of three semesters. Following a baseline assessment, the network was divided into two groups, brief motivational intervention (BMI) and natural history control (NHC) according to dormitory residence location. A subset of heavy drinkers in each group was selected, and those in the BMI group received an in-person intervention.

RESULTS

Using stochastic actor-oriented modeling, we found a significant tendency for participants in the BMI group to shed ties with individuals with similar drinking behaviors between the first and second semesters, relative to the NHC group. Furthermore, heavy drinkers with reciprocal ties to intervention recipients in the BMI group showed a significant reduction in drinks per week.

CONCLUSIONS

Individual alcohol interventions appear to have effects both on behavior and network connections among individuals who did not receive the intervention. Continued research is needed to identify the optimal conditions for the diffusion of behavior change.

Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System

OBJECTIVES

Low back pain is a common clinical presentation that often results in expensive and unnecessary imaging that may lead to undue patient harm, including unnecessary procedures. We present an initiative in a safety net system to reduce imaging for low back pain.

METHODS

This quality improvement study was conducted across 70 ambulatory clinics and 11 teaching hospitals. Three electronic health record changes, using the concept of a nudge, were introduced into orders for lumbar radiography (x-ray), lumbar CT, and lumbar MRI. The primary outcome was the number of orders per 1,000 patient-days or encounters for each imaging test in the inpatient, ambulatory, and emergency department (ED) settings. Variation across facilities was assessed, along with selected indications.

RESULTS

Across all clinical environments, there were statistically significant decreases in level differences pre- and postintervention for lumbar x-ray (-52.9% for inpatient encounters, P < .001; -23.7% for ambulatory encounters, P < .001; and -17.3% for ED only encounters, P < .01). There was no decrease in ordering of lumbar CTs in the inpatient and ambulatory settings, although there was an increase in lumbar CTs in ED-only encounters. There was no difference in lumbar MRI ordering. Variation was seen across all hospitals and clinics.

DISCUSSION

Our intervention successfully decreased lumbar radiography across all clinical settings, with a reduction in lumbar CTs in the inpatient and ambulatory settings. There were no changes for lumbar MRI orders.

Evaluation of an innovative mHealth-based integrated modality for smoking cessation in Chinese smokers: protocol for a randomized controlled trial

BACKGROUND AND AIMS

Developing accessible, affordable, and effective approaches to smoking cessation is crucial for tobacco control. Mobile health (mHealth) based interventions have the potential to aid smokers in quitting, and integrating treatments from multiple sources may further enhance their accessibility and effectiveness. As part of our efforts in smoking cessation, we developed a novel behavioral intervention delivery modality for smoking cessation that integrated three interventions using the WeChat app, called the "Way to Quit" modality (WQ modality). It is presented here the protocol for a randomized controlled trial evaluating the effectiveness, feasibility, and cost-effectiveness of the WQ modality in Chinese smokers.

METHODS

Eligible participants (n = 460) will be recruited via online advertisement in Beijing, China. They will be randomly assigned to receive either quitline-based treatment (QT, n = 230) or WQ modality-based treatment (WQ, n = 230) using a block randomization method. Participants in the QT group will receive telephone-assisted treatment over a four-week period (multi-call quitline protocol), while those in the WQ group will receive integrated interventions based on the WQ modality for four weeks. A four-week supply of nicotine replacement therapy (gums) will be provided to all participants. Participants will be asked to complete phone or online follow-up at 1, 3, 6, and 12-months. At 1-month follow-up, individuals with self-reported smoking abstinence for more than 7 days will be invited to receive an exhaled carbon monoxide (CO) test for biochemical validation. The primary aim is to determine whether the WQ modality is effective in assisting smokers in quitting smoking. The secondary aims are to evaluate the acceptability, satisfaction, and cost-effectiveness of the WQ modality.

DISCUSSION

If the WQ modality is determined to be effective, acceptable, and affordable, it will be relatively easy to reach and provide professional cessation treatments to the communities, thus helping to reduce the disparities in smoking cessation services between different regions and socioeconomic groups.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2200066427, Registered December 5, 2022.

The formation of physician altruism

We study how patient-regarding altruism is formed by medical education. We elicit and structurally estimate altruistic preferences using experimental data from a large sample of medical students (N = 733) in Germany at different progress stages in their studies. The estimates reveal substantial heterogeneity in altruistic preferences of medical students. Patient-regarding altruism is highest for freshmen, significantly declines for students in the course of medical studies, and tends to increase again for last year students, who assist in clinical practice. Also, patient-regarding altruism is higher for females and positively associated to general altruism. Altruistic medical students have gained prior practical experience in healthcare, have lower income expectations, and are more likely to choose surgery and pediatrics as their preferred specialty.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

Background

Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.

Methods

We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).

Discussion

De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.

Trial registration

ClinicalTrials.govNCT05020418

A Pragmatic Randomized Controlled Trial to Increase PrEP Uptake for HIV Prevention: 55-Week Results From PrEPChicago

OBJECTIVES

We tested preliminary efficacy of a peer change agent type I network intervention to increase pre-exposure prophylaxis (PrEP) linkage to care among network members connected to young Black men who have sex with men.

DESIGN

Parent study is a pragmatic randomized controlled trial with 110 weeks of total follow-up. Interim midpoint analyses are performed here using participant data before crossover assignment at 55 weeks.

METHODS

We randomly assigned 423 participants in Chicago to receive the network intervention, an opinion leader workshop with telephonic booster sessions, versus a time-matched control from 2016 to 2018. The consolidated surrogate outcome was PrEP referral and linkage to clinical care among network members connected to study participants and was collected from independent administrative data.

RESULTS

Each study participant in the trial (n = 423) had on average 1822 network contacts who could be eligible for PrEP referral and linkage. During the 55-week observation period, PrEP referral was most likely to occur within 3 days of an intervention session compared to control [odds ratio (OR) 0.07 (0.02-0.013); P = 0.007] resulting in 1-2 referrals of network members per session. Network members with referral or linkage were more likely to be connected to study participants in the intervention arm than the control condition [aOR 1.50 (1.09-2.06); P = 0.012].

CONCLUSIONS

A peer change agent type I network intervention is preliminarily effective at diffusing PrEP through a network of individuals highly susceptible to HIV over 55 weeks. This low-intensity intervention demonstrated network-level impact among populations that have experienced limited PrEP care engagement in the United States.

Determinants of diffusion of environmental sustainability innovations in hospitals of Bihar state in India

Purpose

This paper aims to examine the effect of the characteristics of innovation and change adopters on the rate of adoption of environmental sustainability innovations in hospitals of Bihar state in India.

Design/methodology/approach

Data were collected from hospital administration, managers, doctors, nurses and staff working at various levels in both public and private hospitals of Bihar. Research model was tested using regression analysis with the help of statistical package for social sciences 24.

Findings

Innovation characteristics of relative advantage, simplicity, trialability and compatibility were found to significantly predict the adoption of eco-innovations while innovativeness and environmental opinion leadership failed to demonstrate any significant impact on sustainability adoption in hospitals.

Originality/value

This study provides important information to the change agents on how to diffuse green innovations in the unsustainable and inefficient areas and make them more sustainable. With no systematic investigation of sustainability innovations being done in the health-care sector in India, this study on eco-innovations in a resource-constrained state of India provides a fresh perspective and practical insights on the state of sustainability innovations in health care.

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.

Using a Collaborative, Virtual Discussion Platform to Mobilize Oncologic Expertise for the COVID-19 Pandemic

PURPOSE

COVID-19 is a rapidly emerging worldwide pandemic that has drastically changed health care across the United States. Oncology patients are especially vulnerable. Novel point-of-care resources may be useful to rapidly disseminate peer-reviewed information from oncology experts nationwide. We describe our initial experience with distributing this information through a private, curated, virtual collaboration question-and-answer (Q&A) platform for oncologists.

METHODS

The Q&A database was queried for a 2-month period from March 12 to May 12, 2020. We collected the total number of views and unique viewers for the questions. We classified the questions according to their emphasis (practice management, clinical management, both) and disease type across radiation oncology, medical oncology, gynecologic oncology, and pediatric oncology.

RESULTS

Seventy-nine questions were approved, 67 of which were answered and generated 49,494 views with 5,148 unique viewers. Most discussions covered clinical management, with breast cancer being the most active disease site. Ten questions covered pediatric oncology and gynecologic oncology. Forty-seven percent of the 11,010 users of the platform visited the website during the 2-month period.

CONCLUSION

Discussions on the Q&A platform reached a substantial number of oncologists throughout the nation and may help oncologists to modify their treatment in real time with the rapidly evolving COVID-19 pandemic.

Pharmacogenetics in primary care

The use of pharmacogenetic information is becoming mainstream with insurance companies and others starting to pay for widescale implementation of this new technology starting with patients who have anxiety and depression. It has been introduced in response to the unpredictability of medication, the high number of adverse drug events, and lack of drug effectiveness. Greater than one-third of patients are identified as having one or more pharmacogenetic variants. Each pharmacogenetic variant may affect the metabolism of several medications used in primary care, in addition to the antidepressant and anti-anxiolytic medications. Pharmacogenetic information is evolving with major international working groups providing continuous updates. It is challenging to incorporate this new information along with all the other variables needed to identify safe and effective drug options within a normal consultation. Medication decision support software is one solution that can help address this.

Contextual Factors Influencing Implementation of Evidence-Based Care for Children Hospitalized With Asthma

BACKGROUND AND OBJECTIVES

The translation of research findings into routine care remains slow and challenging. We previously reported successful implementation of an asthma evidence-based care process model (EB-CPM) at 8 (1 tertiary care and 7 community) hospitals, leading to a high health care provider (HCP) adherence with the EB-CPM and improved outcomes. In this study, we explore contextual factors perceived by HCPs to facilitate successful EB-CPM implementation.

METHODS

Structured and open-ended questions were used to survey HCPs (n = 260) including physicians, nurses, and respiratory therapists, about contextual factors perceived to facilitate EB-CPM implementation. Quantitative analysis was used to identify significant factors (correlation coefficient ≥0.5; P ≤ .05) and qualitative analysis to assess additional facilitators.

RESULTS

Factors perceived by HCPs to facilitate EB-CPM implementation were related to (1) inner setting (leadership support, adequate resources, communication and/or collaboration, culture, and previous experience with guideline implementation), (2) intervention characteristics (relevant and applicable to the HCP's practice), (3) individuals (HCPs) targeted (agreement with the EB-CPM and knowledge of supporting evidence), and (4) implementation process (participation of HCPs in implementation activities, teamwork, implementation team with a mix of expertise and professional's input, and data feedback). Additional facilitators included (1) having appropriate preparation and (2) providing education and training.

CONCLUSIONS

Multiple factors were associated with successful EB-CPM implementation and may be used by others as a guide to facilitate implementation and dissemination of evidence-based interventions for pediatric asthma and other chronic diseases in the hospital setting.

Hospital-Based Quality Improvement Interventions for Patients With Acute Coronary Syndrome: A Systematic Review

BACKGROUND

Quality improvement initiatives have been developed to improve acute coronary syndrome care largely in high-income country settings. We sought to synthesize the effect size and quality of evidence from randomized controlled trials (RCTs) and nonrandomized studies for hospital-based acute coronary syndrome quality improvement interventions on clinical outcomes and process of care measures for their potential implementation in low- and middle-income country settings.

METHODS AND RESULTS

We conducted a bibliometric search of databases and trial registers and a hand search in 2016 and performed an updated search in May 2018 and May 2019. We performed data extraction, risk of bias assessment, and quality of evidence assessments in duplicate. We assessed differences in outcomes by study design comparing RCTs to nonrandomized quasi-experimental studies and by country income status. A meta-analysis was not feasible due to substantial, unexplained heterogeneity among the included studies, and thus, we present a qualitative synthesis. We screened 5858 records and included 32 studies (14 RCTs [n=109 763] and 18 nonrandomized quasi-experimental studies [n=54-423]). In-hospital mortality ranged from 2.1% to 4.8% in the intervention groups versus 3.3% to 5.1% in the control groups in 5 RCTs (n=55 942). Five RCTs (n=64 313) reported 3.0% to 31.0% higher rates of reperfusion for patients with ST-segment-elevation myocardial infarction in the intervention groups. The effect sizes for in-hospital and discharge medical therapies in a majority of RCTs were 3.0% to 10.0% higher in the intervention groups. There was no significant difference in 30-day mortality evaluated by 4 RCTs (n=42 384), which reported 2.5% to 15.0% versus 5.9% to 22% 30-day mortality rates in the intervention versus control groups. In contrast, nonrandomized quasi-experimental studies reported larger effect sizes compared to RCTs. There were no significant consistent differences in outcomes between high-income and middle-income countries. Low-income countries were not represented in any of the included studies.

CONCLUSIONS

Hospital-based acute coronary syndrome quality improvement interventions have a modest effect on process of care measures but not on clinical outcomes with expected differences by study design. Although quality improvement programs have an ongoing and important role for acute coronary syndrome quality of care in high-income country settings, further research will help to identify key components for contextualizing and implementing such interventions to new settings to achieve their desired effects. Systematic Review Registration: URL: https://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42016047604.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Barriers to Pediatric Sickle Cell Disease Guideline Recommendations

National guidelines recommend that providers counsel all patients with sickle cell anemia about hydroxyurea (HU) therapy and screen children with sickle cell anemia annually for the risk of stroke with transcranial Doppler (TCD). We surveyed a national convenience sample of sickle cell disease clinicians to assess factors associated with low adherence. Adherence was 46% for TCD screening. Low adherence was associated with a lack of outcome expectancy (eg, a belief that there would be poor patient follow-up to TCD testing; P < .05). Adherence was 72% for HU counseling. Practice barriers (eg, lack of support staff or time) and a lack of agreement with HU recommendations were associated with low adherence (P < .05). This study demonstrates that different types of strategies are needed to improve TCD screening (to address follow-up and access to testing) versus HU counseling (to address physician agreement and practice barriers).

Optimization of Diagnosis and Treatment of Chronic Diseases Based on Association Analysis Under the Background of Regional Integration

In order to improve medical quality, shorten hospital stays, and reduce redundant treatment, an optimization of diagnosis and treatment of chronic diseases based on association analysis under the background of regional integration in the paper was proposed, which was to expand the scope of application of the clinical pathway standard diagnosis and treatment program in the context of regional medical integration and mass medical data, so that it had a larger group of patients within the region. In the context of regional medical integration, owing to the types of medical data were diverse, the preprocessing requirements and process specifications for diagnosis and treatment data were firstly proposed. At the stage of diagnosis and treatment unit optimization, the correlation between clinical behaviors was analyzed by using association rules of the FP-growth and Apriori algorithm. Through the optimization and combination of diagnosis and treatment units, the optimized clinical pathway was finally achieved. Experiments showed that after the optimization strategy by the paper proposed, the clinical path diagnosis and treatment achieved obvious improvement in medical quality under the condition that the medical cost was basically flat.

Effects of an Implementation Intervention to Promote Use of Patient-Reported Outcome Measures on Clinicians' Perceptions of Evidence-Based Practice, Implementation Leadership, and Team Functioning

INTRODUCTION

Patient-reported outcome measures (PROMs) are administered rarely during rehabilitation hospitalizations because clinicians are unfamiliar with their use and the technology to integrate PROMs into electronic medical records is nascent. This study evaluated an implementation intervention that targeted teams' perceptions of evidence-based practice (EBP), implementation leadership, and team functioning that might facilitate PROM use.

METHODS

We compared clinicians' perceptions on three inpatient rehabilitation units, with sequential implementation across units. Clinicians completed the EBP Attitudes Scale, Implementation Leadership Scale, and the Team Functioning Survey before, shortly after, and 1 month after training.

RESULTS

Forty-seven clinicians participated, including nurses (27.7%), occupational (21.3%) and physical therapists (21.3%), and two physicians. They worked on spinal cord injury (46.8%), neurologic (40.4%), or pediatric (12.8%) units. EBP Attitude Scale scores improved from preintervention to postintervention and remained above baseline levels at follow-up. The interaction between time and unit was statistically significant for the Divergence subscale such that Pediatric Unit scores increased from preintervention to postintervention and follow-up, while on the spinal cord injury, unit scores increased from preintervention to postintervention, and on the Neurologic Unit scores declined from preintervention to postintervention and follow-up. The EBP Attitudes Requirements score increased at postintervention and follow-up. The Implementation Leadership Scale Proactive score and team functioning survey scores decreased slightly.

DISCUSSION

Implementing PROMs had varied effects on EBP attitudes and perceptions of leadership and team functioning. Perceptions across units were distinctive on the Evidence-Based Practice Attitudes Scale Divergence subscale. Introduction of PROMs should consider clinician attitudes regarding EBP as well as implementation leadership and team functioning.

Continuing Education Meets the Learning Organization: The Challenge of a Systems Approach to Patient Safety

Since the release of the report of the Institute of Medicine on medical errors and patient safety in November 1999, health policy makers and health care leaders in several nations have sought solutions that will improve the safety of health care. This attention to patient safety has highlighted the importance of a learning approach and a systems approach to quality measurement and improvement. Balanced with the need for public disclosure of performance, confidential reporting with feedback is one of the prime ways that nations such as the United States, Canada, the United Kingdom, and Australia have approached this challenge. In the United States, the Quality Interagency Coordination Task Force has convened federal agencies that are involved in health care quality improvement for a coordinated initiative. Based on an investment in a strong research foundation in health care quality measurement and improvement, there are eight key lessons for continuing education if it is to parlay the interest in patient safety into enhanced continuing education and quality improvement in learning health care systems. The themes for these lessons are (1) informatics for information, (2) guidelines as learning tools, (3) learning from opinion leaders, (4) learning from the patient, (5) decision support systems, (6) the team learning together, (7) learning organizations, and (8) just-in-time and point-of care delivery.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

ADDRESSING THE OPIOID EPIDEMIC: IS THERE A ROLE FOR PHYSICIAN EDUCATION?

Using national data on opioid prescriptions written by physicians from 2006 to 2014, we uncover a striking relationship between opioid prescribing and medical school rank. Even within the same specialty and practice location, physicians who completed their initial training at top medical schools write significantly fewer opioid prescriptions annually than physicians from lower ranked schools. Additional evidence suggests that some of this gradient represents a causal effect of education rather than patient selection across physicians or physician selection across medical schools. Altering physician education may therefore be a useful policy tool in fighting the current epidemic.

An exploratory study of networks constructed using access data from an electronic health record

Network analysis may be a powerful tool for studying interprofessional practice. Using electronic health record data and social network analysis, the network of healthcare professionals involved in colorectal cancer care at a large, urban academic medical center were mapped and studied. A total of 100 surgical colorectal cancer patients receiving treatment in 2013 and 2014 were selected at random. We used detailed access logs for the EHR to map the network of all healthcare professionals for each patient, including inpatient and outpatient settings. Approximately 2.45 million records of access logs from more than 6,800 unique users, representing over 150 roles or occupations were analyzed. Across all networks, professionals were connected to an average of 5.8 other professionals, but some were rarely connected with others while over 20 were very highly connected (> 100 other professionals). Housestaff, attending physicians, and nurses played central roles in the global network with a high number of inter- and intra-professional connections. Clusters of professionals with frequent interaction were demonstrated but, based on the size and complexity of the network, serendipitous interactions were unlikely. Settings for care seemed to influence these clusters. Patient-centric care networks were similar to the global network with some potentially important differences. Access-log information from electronic health records can be an important source of information about relationships between healthcare professionals. Findings from analyses such as this one may help define the state of current networks and potential targets for interventions to improve the quality of care.

Does a quality improvement campaign accelerate take-up of new evidence? A ten-state cluster-randomized controlled trial of the IHI's Project JOINTS

Background

A decade ago, the Institute for Healthcare Improvement pioneered a quality improvement (QI) campaign, leveraging organizational and personal social networks to disseminate new practices. There have been few rigorous studies of the QI campaign approach.

Methods

Project JOINTS (Joining Organizations IN Tackling SSIs) engaged a network of state-based organizations and professionals in a 6-month QI campaign promoting adherence to three new evidence-based practices known to reduce the risk of infection after joint replacement. We conducted a cluster-randomized trial including ten states (five campaign states and five non-campaign states) with 188 hospitals providing joint replacement to Medicare. We measured adherence to the evidence-based practices before and after the campaign using a survey of surgical staff and a difference-in-difference design with multivariable adjustment to compare adherence to each of the relevant practices and an all-or-none composite measure of the three new practices.

Results

In the campaign states, there were statistically significant increases in adherence to the three new evidence-based practices promoted by the campaign. Compared to the non-campaign states, the relative increase in adherence to the three new practices in the campaign states ranged between 1.9 and 15.9 percentage points, but only one of these changes (pre-operative nasal screening for Staphylococcus aureus carriage and decolonization prior to surgery) was statistically significant (p < 0.05). On the all-or-none composite measure, adherence to all three evidence-based practices increased from 19.6 to 37.9% in the campaign states, but declined slightly in the comparison states, yielding a relative increase of 23 percentage points (p = 0.004). In the non-campaign states, changes in adherence were not statistically significant.

Conclusions

Within 6 months, in a cluster-randomized trial, a multi-state campaign targeting hospitals and professionals involved in surgical care and infection control was associated with an increase in adherence to evidence-based practices that can reduce surgical site infection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0579-7) contains supplementary material, which is available to authorized users.

Strategies for Translating Evidence-Based Medicine in Lung Cancer into Community Practice

The landscape of non-small cell lung cancer (NSCLC) treatment has rapidly evolved over the past decade. This is exemplified by the use of molecular targeted agents, immunotherapies, and newer technologies such as stereotactic body radiotherapy (SBRT). As the translation of preclinical discoveries into clinical practice continues, the effective dissemination and implementation of evidence-based treatment of NSCLC will remain a foremost challenge for oncologists. To further extend evidence-based medicine into the community setting, community oncologists are being engaged on multiple fronts including leadership and participation in national clinical trials and utilization of internet-based resources.

Space-Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs

OBJECTIVE

To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA.

DATA SOURCES

VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database.

STUDY DESIGN

We conducted a retrospective space-time cluster analysis using the space-time permutation statistic.

DATA EXTRACTION METHODS

All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication.

PRINCIPAL FINDINGS

The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely.

CONCLUSIONS

Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics.

Treatment Intensification for Hypertension in US Ambulatory Medical Care

Background

Hypertension is widely prevalent yet remains uncontrolled in nearly half of US hypertensive adults. Treatment intensification for hypertension reduces rates of major cardiovascular events and all‐cause mortality, but clinical inertia remains a notable impediment to further improving hypertension control. This study examines the likelihood and determinants of treatment intensification with new medication in US ambulatory medical care.

Methods and Results

Using the nationally representative National Ambulatory Medical Care Survey (2005–2012) and National Hospital Ambulatory Medical Care Survey (2005–2011), we identified adult primary care visits with diagnosed hypertension and documented blood pressure exceeding goal targets and assessed the weighted prevalence and odds ratios of treatment intensification by initiation or addition of new medication. Approximately 41.7 million yearly primary care visits (crude N: 14 064, 2005–2012) occurred among US hypertensive adults with documented blood pressure ≥140/90 mm Hg, where treatment intensification may be beneficial. However, only 7.0 million of these visits (95% confidence interval 6.2–7.8 million) received treatment intensification with new medication, a weighted prevalence of 16.8% (15.8% to 17.9%). This proportion was consistently low and decreased over time. This decline was largely driven by decreasing medication initiation levels among patients on no previous hypertension medications from 31.8% (26.0% to 38.4%) in 2007 to 17.4% (14.0% to 21.4%) in 2012, while medication addition levels remained more stable over time.

Conclusions

US hypertensive adults received treatment intensification with new medication in only 1 out of 6 primary care visits, a fraction that is declining over time. A profound increase in intensification remains a vast opportunity to maximally reduce hypertension‐related morbidity and mortality nationwide.

The Impact of Unstable Angina Guidelines in the Triage of Emergency Department Patients with Possible Acute Coronary Syndrome

Objective. The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain. Methods. The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups. Results. No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS. Conclusion. Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.

The Role of Physicians and Certification Boards to Improve Quality

Amid growing focus on individual physician performance, it is timely to examine what evidence exists that physicians can be facilitators and leaders for health care quality improvement in their local health care environments. Despite the importance of governmental policy and national initiatives, change in health care quality must occur in the context of local communities. Therefore, individual physician involvement, working with other local health care leaders and providers, will be crucial to future quality improvement. The objectives of this article are as follows: (1) outline why physicians must be involved in quality improvement, (2) delineate the barriers and facilitators to physician involvement, and (3) discuss how medical certification boards can facilitate greater physician involvement in quality improvement.

Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A Cluster-Randomized Field Trial in Ghana

We used a cluster-randomized field trial to evaluate training natural leaders (NLs) as an addition to a community-led total sanitation (CLTS) intervention in Ghana. NLs are motivated community members who influence their peers' behaviors during CLTS. The outcomes were latrine use and quality, which were assessed from surveys and direct observation. From October 2012, Plan International Ghana (Plan) implemented CLTS in 60 villages in three regions in Ghana. After 5 months, Plan trained eight NLs from a randomly selected half of the villages, then continued implementing CLTS in all villages for 12 more months. The NL training led to increased time spent on CLTS by community members, increased latrine construction, and a 19.9 percentage point reduction in open defecation (p < 0.001). The training had the largest impact in small, remote villages with low exposure to prior water and sanitation projects, and may be most effective in socially cohesive villages. For both interventions, latrines built during CLTS were less likely to be constructed of durable materials than pre-existing latrines, but were equally clean, and more often had handwashing materials. CLTS with NL training contributes to three parts of Goal 6 of the Sustainable Development Goals: eliminating open defecation, expanding capacity-building, and strengthening community participation.

Assessment of Screening, Treatment, and Prevention of Perinatal Infections in the Philadelphia Birth Cohort

Certain population groups are at risk for inadequate prenatal care and transmission of perinatal infections. Philadelphia's birth cohort comprises largely at-risk groups and its infant mortality rate is among the nation's highest. This study identifies factors associated with infectious disease screening, treatment, and prevention in Philadelphia. Delivery charts for a probability sample of 550 patients were reviewed. Demographic factors associated with prenatal and delivery care were identified through Pearson chi-square, analysis of variance, and stepwise logistic regression analysis. Nonstandard and incomplete documentation complicated abstraction. Some prenatal care was noted in 95% of the records and screening varied by disease. Factors independently associated with care include maternal race, insurance status, and maternal age. Screening for infections with well-established recommendations (hepatitis B virus, rubella, syphilis) occurred more often than for group B streptococcus, HIV, hepatitis C virus, and varicella. Adoption of standard reporting forms and processes could improve practice and aid in quality improvement efforts and patient communication.

From evidence to clinical practice in blood and marrow transplantation

Clinical practice in the field of blood and marrow transplantation (BMT) has evolved over time, as a result of thousands of basic and clinical research studies. While it appears that scientific discovery and adaptive clinical research may be well integrated in case of BMT, there is lack of sufficient literature to definitively understand the process of translation of evidence to practice and if it may be selective . In this review, examples from BMT and other areas of medicine are used to highlight the state of and potential barriers to evidence uptake. Strategies to help improve knowledge transfer are discussed and the role of existing framework provided by the Center for International Blood and Marrow Transplant Registry (CIBMTR) to monitor uptake and BMT Clinical Trials Network (BMT CTN) to enhance translation of evidence into practice is highlighted.

Evidence-Based Practice: The Psychology of EBP Implementation

Evidence-based practice (EBP) is an approach used in numerous professions that focuses attention on evidence quality in decision making and action. We review research on EBP implementation, identifying critical underlying psychological factors facilitating and impeding its use. In describing EBP and the forms of evidence it employs, we highlight the challenges individuals face in appraising evidence quality, particularly that of their personal experience. We next describe critical EBP competencies and the challenges underlying their acquisition: foundational competencies of critical thinking and domain knowledge, and functional competencies such as question formulation, evidence search and appraisal, and outcome evaluation. We then review research on EBP implementation across diverse fields from medicine to management and organize findings around three key contributors to EBP: practitioner ability, motivation, and opportunity to practice (AMO). Throughout, important links between psychology and EBP are highlighted, along with the contributions psychological research can make to further EBP development and implementation.

Physician's peer exposure and the adoption of a new cancer treatment modality

BACKGROUND

New technologies, often with limited evidence to support their effectiveness, frequently diffuse into clinical practice and increase the costs of cancer care. The authors studied whether physician peer exposure was associated with the subsequent adoption of a new approach to adjuvant radiotherapy (brachytherapy) for the treatment of women with early-stage breast cancer.

METHODS

A retrospective cohort study was performed using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Data from 2003 through 2004 were used to classify surgeons as early brachytherapy adopters and, among non-early adopters, whether they shared patients with early adopters (peer exposure). Data from 2005 through 2006 were used to examine whether women were more likely to receive brachytherapy if their surgeons were exposed to early adopters.

RESULTS

Overall, the percentage of women receiving brachytherapy increased from 3.2% in 2003 through 2004 to 4.7% in 2005 through 2006. In this latter period, a total of 2087 patients were assigned to 328 non-early adopting surgeons. In unadjusted analyses, patients whose surgeons were connected to early adopters during 2003 through 2004 were found to be significantly more likely to receive brachytherapy in 2005 through 2006 compared with those whose surgeons were not connected to early adopters (8.0% vs 4.1%; P = .003). In adjusted analyses, the predicted probability of receiving brachytherapy among patients whose surgeon did have an early-adopting peer was 3.9% versus 1.0% among those whose surgeons did not have an early-adopting peer (P = .03).

CONCLUSIONS

Exposure to peers who were early adopters of brachytherapy was found to be associated with a surgeon's subsequent uptake of brachytherapy. The results of the current study provide an example of a novel approach to examining the diffusion of innovation in cancer care.

Going above and beyond for implementation: the development and validity testing of the Implementation Citizenship Behavior Scale (ICBS)

Background

In line with recent research on the role of the inner context of organizations in implementation effectiveness, this study extends research on organizational citizenship behavior (OCB) to the domain of evidence-based practice (EBP) implementation. OCB encompasses those behaviors that go beyond what is required for a given job that contribute to greater organizational effectiveness. The goal of this study was to develop and test a measure of implementation citizenship behavior (ICB) or those behaviors that employees perform that go above and beyond what is required in order to support EBP implementation.

Methods

The primary participants were 68 supervisors from ten mental health agencies throughout California. Items measuring ICB were developed based on past research on OCB and in consultation with experts on EBP implementation in mental health settings. Supervisors rated 357 of their subordinates on ICB and implementation success. In addition, 292 of the subordinates provided data on self-rated performance, attitudes towards EBPs, work experience, and full-time status. The supervisor sample was randomly split, with half used for exploratory factor analyses and the other half for confirmatory factor analyses. The entire sample of supervisors and subordinates was utilized for analyses assessing the reliability and construct validity of the measure.

Results

Exploratory factor analyses supported the proposed two-factor structure of the Implementation Citizenship Behavior Scale (ICBS): (1) Helping Others and (2) Keeping Informed. Confirmatory factor analyses with the other half of the sample supported the factor structure. Additional analyses supported the reliability and construct validity for the ICBS.

Conclusions

The ICBS is a pragmatic brief measure (six items) that captures critical behaviors employees perform to go above and beyond the call of duty to support EBP implementation, including helping their fellow employees on implementation-related activities and keeping informed about issues related to EBP and implementation efforts. The ICBS can be used by researchers to better understand the outcomes of improved organizational support for implementation (i.e., implementation climate) and the proximal predictors of implementation effectiveness. The ICBS can also provide insight for organizations, practitioners, and managers by focusing on key employee behaviors that should increase the probability of implementation success.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0255-8) contains supplementary material, which is available to authorized users.

Tailored interventions to address determinants of practice

BACKGROUND

Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.

OBJECTIVES

To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants.

SEARCH METHODS

We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals.

SELECTION CRITERIA

Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.

MAIN RESULTS

We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.

AUTHORS' CONCLUSIONS

Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis

Medicare reimbursement policy encourages frequent provider visits for patients with ESRD undergoing hemodialysis. We hypothesize that patients seen more frequently by their nephrologist or advanced practitioner within the first 90 days of hemodialysis are more likely to undergo surgery to create an arteriovenous (AV) fistula or place an AV graft. We selected 35,959 patients aged ≥67 years starting hemodialysis in the United States from a national registry. We used multivariable regression to evaluate the associations between mean visit frequency and AV fistula creation or graft placement in the first 90 days of hemodialysis. We conducted an instrumental variable analysis to test the sensitivity of our findings to potential bias from unobserved characteristics. One additional visit per month in the first 90 days of hemodialysis was associated with a 21% increase in the odds of AV fistula creation or graft placement during that period (95% confidence interval, 19% to 24%), corresponding to an average 4.5% increase in absolute probability. An instrumental variable analysis demonstrated similar findings. Excluding visits in months when patients were hospitalized, one additional visit per month was associated with a 10% increase in odds of vascular access surgery (95% confidence interval, 8% to 13%). In conclusion, patients seen more frequently by care providers in the first 90 days of hemodialysis undergo earlier AV fistula creation or graft placement. Payment policies that encourage more frequent visits to patients at key clinical time points may yield more favorable health outcomes than policies that operate irrespective of patients' health status.

Adoption of a High-Impact Innovation in a Homogeneous Population

Adoption of innovations, whether new ideas, technologies, or products, is crucially important to knowledge societies. The landmark studies of adoption dealt with innovations having great societal impact (such as antibiotics or hybrid crops) but where determining the utility of the innovation was straightforward (such as fewer side effects or greater yield). Recent large-scale studies of adoption were conducted within heterogeneous populations and focused on products with little societal impact. Here, we focus on a case with great practical significance: adoption by small groups of highly trained individuals of innovations with large societal impact but for which it is impractical to determine the true utility of the innovation. Specifically, we study experimentally the adoption by critical care physicians of a diagnostic assay that complements current protocols for the diagnosis of life-threatening bacterial infections and for which a physician cannot estimate the true accuracy of the assay based on personal experience. We show through computational modeling of the experiment that infection-spreading models-which have been formalized as generalized contagion processes-are not consistent with the experimental data, while a model inspired by opinion models is able to reproduce the empirical data. Our modeling approach enables us to investigate the efficacy of different intervention schemes on the rate and robustness of innovation adoption in the real world. While our study is focused on critical care physicians, our findings have implications for other settings in education, research, and business, where small groups of highly qualified peers make decisions about the adoption of innovations whose utility is difficult if not impossible to gauge.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing.

OBJECTIVES

This review sought to determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'.

SELECTION CRITERIA

A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome.

MAIN RESULTS

Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.

Measuring the effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: a systematic review

BACKGROUND

Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice.

AIM

To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals' use of evidence in clinical practice.

METHODS

A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentee's needs; and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively.

RESULTS

Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners' knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals' behaviors and impact on practitioners' and patients' outcomes: some outcomes improved, while others showed no difference.

LINKING EVIDENCE TO ACTION

Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.

Consequences of ADHD medication use for children's outcomes

This paper estimates effects of early ADHD medication use on key human capital outcomes for children diagnosed with ADHD while using rarely available register based data on diagnoses and prescription drug purchases. Our main identification strategy exploits plausible exogenous assignment of children to hospitals with specialist physicians, while our analysis of health outcomes also allows for an individual level panel data strategy. We find that the behavior of specialist physicians varies considerably across hospitals and that the prescribing behavior does affect the probability that a given child is treated. Results show that children diagnosed with ADHD in pharmacological treatment have fewer hospital contacts if treated and that treatment to some extent protects against criminal behavior.

Physician social networks and variation in rates of complications after radical prostatectomy

OBJECTIVES

Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy.

METHODS

In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume.

RESULTS

Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications.

CONCLUSIONS

Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

Interinstitutional variation in management decisions for treatment of 4 common types of cancer: A multi-institutional cohort study

BACKGROUND

When clinical practice is governed by evidence-based guidelines and there is consensus about their validity, practice variation should be minimal. For areas in which evidence gaps exist, greater variation is expected.

OBJECTIVE

To systematically assess interinstitutional variation in management decisions for 4 common types of cancer.

DESIGN

Multi-institutional, observational cohort study of patients with cancer diagnosed between July 2006 through May 2011 and observed through 31 December 2011.

SETTING

18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network.

PATIENTS

25 589 patients with incident breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma.

MEASUREMENTS

Interinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions.

RESULTS

Interinstitutional variation was high (median absolute deviation >10%) for 35 of 171 (20%) oncology management decisions, including 9 of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, 7 of 47 (15%) for lung cancer, and 3 of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37% involved choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, 2A for 49%, and 2B/other for 51%.

LIMITATION

Physician identifiers were unavailable, and results may not generalize outside of major cancer centers.

CONCLUSION

The substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness research, patient-provider education, or pathway development.

PRIMARY FUNDING SOURCE

National Cancer Institute and National Comprehensive Cancer Network.

Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized trial

Background

Despite significant increases in global health investment and the availability of low-cost, efficacious interventions to prevent mother-to-child HIV transmission (pMTCT) in low- and middle-income countries with high HIV burden, the translation of scientific advances into effective delivery strategies has been slow, uneven and incomplete. As a result, pediatric HIV infection remains largely uncontrolled. A five-step, facility-level systems analysis and improvement intervention (SAIA) was designed to maximize effectiveness of pMTCT service provision by improving understanding of inefficiencies (step one: cascade analysis), guiding identification and prioritization of low-cost workflow modifications (step two: value stream mapping), and iteratively testing and redesigning these modifications (steps three through five). This protocol describes the SAIA intervention and methods to evaluate the intervention’s impact on reducing drop-offs along the pMTCT cascade.

Methods

This study employs a two-arm, longitudinal cluster randomized trial design. The unit of randomization is the health facility. A total of 90 facilities were identified in Côte d’Ivoire, Kenya and Mozambique (30 per country). A subset was randomly selected and assigned to intervention and comparison arms, stratified by country and service volume, resulting in 18 intervention and 18 comparison facilities across all three countries, with six intervention and six comparison facilities per country. The SAIA intervention will be implemented for six months in the 18 intervention facilities. Primary trial outcomes are designed to assess improvements in the pMTCT service cascade, and include the percentage of pregnant women being tested for HIV at the first antenatal care visit, the percentage of HIV-infected pregnant women receiving adequate prophylaxis or combination antiretroviral therapy in pregnancy, and the percentage of newborns exposed to HIV in pregnancy receiving an HIV diagnosis eight weeks postpartum. The Consolidated Framework for Implementation Research (CFIR) will guide collection and analysis of qualitative data on implementation process.

Discussion

This study is a pragmatic trial that has the potential benefit of improving maternal and infant outcomes by reducing drop-offs along the pMTCT cascade. The SAIA intervention is designed to provide simple tools to guide decision-making for pMTCT program staff at the facility level, and to identify low cost, contextually appropriate pMTCT improvement strategies.

Trial registration

ClinicalTrials.gov NCT02023658

Physician visits and 30-day hospital readmissions in patients receiving hemodialysis

A focus of health care reform has been on reducing 30-day hospital readmissions. Patients with ESRD are at high risk for hospital readmission. It is unknown whether more monitoring by outpatient providers can reduce hospital readmissions in patients receiving hemodialysis. In nationally representative cohorts of patients in the United States receiving in-center hemodialysis between 2004 and 2009, we used a quasi-experimental (instrumental variable) approach to assess the relationship between frequency of visits to patients receiving hemodialysis following hospital discharge and the probability of rehospitalization. We then used a multivariable regression model and published hospitalization data to estimate the cost savings and number of hospitalizations that could be prevented annually with additional provider visits to patients in the month following hospitalization. In the main cohort (n=26,613), one additional provider visit in the month following hospital discharge was estimated to reduce the absolute probability of 30-day hospital readmission by 3.5% (95% confidence interval, 1.6% to 5.3%). The reduction in 30-day hospital readmission ranged from 0.5% to 4.9% in an additional four cohorts tested, depending on population density around facilities, facility profit status, and patient Medicaid eligibility. At current Medicare reimbursement rates, the effort to visit patients one additional time in the month following hospital discharge could lead to 31,370 fewer hospitalizations per year, and $240 million per year saved. In conclusion, more frequent physician visits following hospital discharge are estimated to reduce rehospitalizations in patients undergoing hemodialysis. Incentives for closer outpatient monitoring following hospital discharge could lead to substantial cost savings.

The effectiveness of the quality program Pac-IficO to improve pain management in hospitalized cancer patients: a before-after cluster phase II trial

Background

Cancer-related pain continues to be a major healthcare issue worldwide. Despite the availability of effective analgesic drugs, published guidelines and educational programs for Health Care Professionals (HCPs) the symptom is still under-diagnosed and its treatment is not appropriate in many patients. The objective of the study is to evaluate the efficacy of the Pac-IFicO programme in improving the quality of pain management in hospitalised cancer patients.

Methods/design

This is a before-after cluster phase II study. After the before assessment, the experimental intervention – the Pac-IFicO programme – will be implemented in ten medicine, oncology and respiratory disease hospital wards. The same assessment will be repeated after the completion of the intervention. The Pac-IFicO programme is a complex intervention with multiple components. It includes focus group with ward professionals for identifying possible local obstacles to optimal pain control, informative material for the patients, an educational program performed through guides from the wards, and an organisational intervention to the ward. The primary end-point of the study is the proportion of cancer patients with severe pain. Secondary end-points include opioids administered in the wards, knowledge in pain management, and quality of pain management. We plan to recruit about 500 cancer patients. This sample size should be sufficient, after appropriate statistical adjustments for clustering, to detect an absolute decrease in the primary end-point from 20% to 9%.

Discussion

This trial is aimed at exploring with an experimental approach the efficacy of a new quality improvement educational intervention.

Trial registration

ClinicalTrials.gov: NCT02035098