Racial Disparities in Evidence-Based Management of Metabolic Dysfunction-Associated Steatotic Liver Disease in Patients With Type 2 Diabetes

OBJECTIVE

To assess frequency of evidence-based management (EBM) of metabolic dysfunction-associated steatotic liver disease (MASLD) in patients with type 2 diabetes (T2D), and to examine for racial/ethnic disparities in the receipt of EBM.

METHODS

We conducted a cross-sectional analysis of patients with T2D and presumptive MASLD in an academic health care system between 2019 and 2021. Presumptive MASLD was defined as at least 1 alanine aminotransferase value ≥30 U/L with exclusions for alcohol overuse, viral hepatitis, liver transplantation, chemotherapy use, and liver disease other than MASLD. We calculated the proportion of patients receiving EBM, defined as a composite of liver ultrasound, transient elastography, or hepatology evaluation. We also examined the association between race/ethnicity and EBM via a logistic regression model.

RESULTS

Our sample included 6532 patients; mean age was 58.0 (SD 13.1), 41.7% were female and 3.9%, 26.6%, 58.7%, and 5.8% were of Latino/a/x ethnicity, non-Latino (NL) Black race, NL White race, and NL Asian race, respectively. Rates of EBM were low overall (11.5%), with lower odds of EBM in NL Black versus NL White patients (adjusted odds ratio 0.75; 95% confidence interval 0.59, 0.96). Odds of hepatology evaluation and placement of MASLD diagnosis codes were also lower in NL Black versus NL White patients.

CONCLUSION

Racial disparities exist in the receipt of EBM among patients with T2D and presumptive MASLD. These findings highlight the need for research to identify drivers of disparities, and to support development of clinical interventions that equitably facilitate EBM of MASLD in patients with T2D.

A Mixed-Methods Evaluation of a Project ECHO Program for the Evidence-Based Management of Sickle Cell Disease

Sickle cell disease (SCD) is a group of chronic, genetic disorders of the red blood cells with significant gaps in access to evidence-based clinical care. Sickle Treatment and Outcomes Research in the Midwest (STORM), a provider network, utilized Project ECHO (Extension for Community Health Outcomes), a telementoring model, to deliver evidence-based education about SCD management. The purpose of this mixed-methods study is to evaluate the utility of Project ECHO as an educational strategy for healthcare providers treating children and adults with SCD. Annual evaluations were administered to STORM TeleECHO participants from 2016 to 2021. Survey data showed a statistically significant change in self-reported provider confidence in the ability to provide care for adult patients with SCD; identify suitable candidates for disease-modifying therapies; and confidence to prescribe disease-modifying therapies. Participants who attended at least 10 sessions were invited to participate in a semi-structured interview. Qualitative data were analyzed using thematic analysis and several themes emerged about the benefits, including (1) increased confidence, (2) integrated best-practice care, (3) connection to provider network and access to experts, (4) high-quality educational presentations and (5) opportunities for collaboration and a sense of community. This suggests that Project ECHO is accessible and leads to increased confidence in providers caring for individuals with SCD. Overall, participant knowledge gains successfully demonstrated the utility of Project ECHO as an educational resource for providers.

The importance of expert selection when identifying threatened ecosystems

Identifying threatened ecosystem types is fundamental to conservation and management decision-making. When identification relies on expert judgment, decisions are vulnerable to inconsistent outcomes and can lack transparency. We elicited judgements of the occurrence of a widespread, critically endangered Australian ecosystem from a diverse pool of 83 experts. We asked 4 questions. First, how many experts are required to reliably conclude that the ecosystem is present? Second, how many experts are required to build a reliable model for predicting ecosystem presence? Third, given expert selection can narrow the range opinions, if enough experts are selected, do selection strategies affect model predictions? Finally, does a diverse selection of experts provide better model predictions? We used power and sample size calculations with a finite population of 200 experts to calculate the number of experts required to reliably assess ecosystem presence in a theoretical scenario. We then used boosted regression trees to model expert elicitation of 122 plots based on real-world data. For a reliable consensus (90% probability of correctly identifying presence and absence) in a relatively certain scenario (85% probability of occurrence), at least 17 experts were required. More experts were required when occurrence was less certain, and fewer were needed if permissible error rates were relaxed. In comparison, only ∼20 experts were required for a reliable model that could predict for a range of scenarios. Expert selection strategies changed modeled outcomes, often overpredicting presence and underestimating uncertainty. However, smaller but diverse pools of experts produced outcomes similar to a model built from all contributing experts. Combining elicited judgements from a diverse pool of experts in a model-based decision support tool provided an efficient aggregation of a broad range of expertise. Such models can improve the transparency and consistency of conservation and management decision-making, especially when ecosystems are defined based on complex criteria.

Fever of Unknown Origin and Atrial Fibrillation: A Case Report

Fever of unknown origin describes a temperature greater than 100.9°F which is present on multiple instances for a period over three weeks with no confirmed diagnosis despite a minimum of three outpatient visits, three days of inpatient testing, or one week of extensive outpatient testing. This diagnosis presents challenges in clinical management due to the unknown etiology. This case highlights a fever of unknown origin presenting with new-onset atrial fibrillation in a patient with no previous cardiac history. A 62-year-old Caucasian male presented to the ED with a nine-day history of intermittent fevers and chills. He returned from a rafting trip in North Carolina two weeks ago but reported no tick bites, animal encounters, or river water ingestion. Further evaluation was significant for an elevated white blood cell count and elevated inflammatory markers. Laboratory and radiologic testing for a wide array of infectious and malignant etiologies were unremarkable. Soon after hospital presentation, he developed a fever of 102.9°F with new onset palpitations and chest tightness due to atrial fibrillation. Episodes of atrial fibrillation continued for his seven-day hospital course with more severe symptoms in the evenings. He was administered broad-spectrum antibiotics and tested extensively with no definitive etiology. His fever curve downtrended with max temperatures below 100.9°F on hospital days six and seven with asymptomatic episodes of atrial fibrillation, prompting discharge. He continued to have low-grade fevers measured below 100.9°F for several days post-discharge with no associated symptoms, resulting in a diagnosis of fever of unknown origin following the 21st day. Fever of unknown origin is a clinical challenge, particularly in cases with no diagnosis discovered and cases with potentially life-threatening complications such as atrial fibrillation. This patient had multiple potential etiologies for his condition, but none had sufficient evidence for diagnosis, resulting in uncertainty regarding the ideal management. As a result, constant monitoring with supportive treatments and broad-spectrum antibiotics was utilized. These measures allowed for symptom remission and hospital discharge for outpatient follow-up. This case highlights a rare presentation of fever of unknown origin with new-onset atrial fibrillation in an otherwise healthy adult.

Influence of Maternal Body Fat on Levels of Insulin, Insulin-Like Growth Factor-1, and Obestatin

BACKGROUND

Insulin, insulin-like Growth Factor-1 (IGF-1), and obestatin in human milk originate from the circulation. There is also limited knowledge about the influence of body fat on the levels of these hormones in human milk.

RESEARCH AIM

To determine (1) the influence of body fat on levels of insulin, IGF-1, and obestatin in human milk and serum/plasma during the postpartum period; (2) the changes in the levels of these hormones in human milk and serum/plasma postpartum; and (3) the presence of IGF-1 mRNA in human milk.

METHODS

In this prospective, longitudinal, observational cohort study, levels of insulin, IGF-1, and obestatin were measured up to 30 days postpartum in milk and serum/plasma of 58 participants with adequate (≤ 32%) or excess (> 32%) total body fat determined by electrical bioimpedance. Student's t test and repeated-measures analysis of variance were used to evaluate the differences between groups. Pearson's test was used to analyze the associations.

RESULTS

The milk from participants with excess body fat had higher insulin and IGF-1 levels and lower obestatin levels than that of participants with adequate body fat at 3-7, 14-15, and 30 days postpartum (adjusted p < .001). The levels of insulin, IGF-1, and obestatin were significantly higher in human milk than in serum/plasma (p < .05) and correlated with maternal body fat (p < .001).

CONCLUSIONS

Maternal body fat was associated with elevated insulin and IGF-1 levels and decreased obestatin levels in human milk up to 30 days postpartum.

Lessons from other disciplines for setting management thresholds for biodiversity conservation

Successful, state-dependent management, in which the goal of management is to maintain a system in a desired state, involves defining the boundaries between different states. Once these boundaries have been defined, managers require a strategic action plan with thresholds that initiate management interventions to either maintain or return the system to a desired state. This approach to management is widely used across diverse industries from agriculture, to medicine, to information technology, but it has only been adopted in conservation management relatively recently. Conservation practitioners have expressed a willingness to integrate this structured approach in their management systems, but they have also voiced concerns, including lack of a robust process for doing so. Given the widespread use of state-dependent management in other fields, we conducted an extensive review of the literature on threshold-based management to gain insight into how and where it is applied and identify potential lessons for conservation management. We identified 22 industries using 75 different methods for setting management thresholds in 843 studies. Methods spanned six broad approaches, including expert driven, statistical, predictive, optimization, experimental, and artificial intelligence methods. The objectives of each of these studies influenced the approaches used, including the methods for setting thresholds and selecting actions, and the number of thresholds set. The role of value judgments in setting thresholds was clear; studies across all industries frequently involved experts in setting thresholds, often accompanied by computational tools to simulate the consequences of proposed thresholds under different conditions. Of the 30 conservation studies examined, two-thirds used expert-driven methods, consistent with prior evidence that experience-based information often drives conservation management decisions. The methods we identified from other disciplines could help conservation decision makers set thresholds for management interventions in different contexts, linking monitoring to management actions and ensuring that conservation interventions are timely and effective.

NCHL's "Best Organizations for Leadership Development" Program: A Case Study in Improving Evidence-based Practice through Benchmarking and Recognition

Increasingly, addressing healthcare's grand challenges requires complex system-level adaptations involving continuously evolving teams and leaders. Although leadership development strategies have been shown to improve individual leader effectiveness, much less is known about how organization-level leadership development affects organization-level outcomes. To begin building an evidence base as well as encouraging evidence-based practices, the US-based National Center for Healthcare Leadership developed a program capitalizing on leaders' demonstrated interest in organizational competitiveness: the biennial Best Organizations for Leadership Development (BOLD) program. In this chapter, we describe the philosophy behind this unique survey program and summarize research to date on relationships between survey dimensions and organizational outcomes such as patient experience and financial performance. We conclude with a description of promising areas for future study.

A Review of the Evidence on Attitudes, Perceived Impacts and Motivational Factors for European Member State Collaboration for Pricing and Reimbursement of Medicines: Time for the EEA Member States to Apply Their Experience and Expertise in Evidence-Based Decision Making to Their Current Pharmaceutical Policy Challenges

In 2018/2019 there were a number of initiatives for collaboration between Member States in the European Economic Area (EEA) and the European Commission published a Proposal for a Regulation on Health Technology Assessment. In view of the perceived benefits from collaboration, the experiences and challenges of these collaborative initiatives and the possible implications of the proposed legislation, a study of the evidence on attitudes, perceived impacts and the motivational factors towards European Member State collaboration regarding the pricing and reimbursement of medicines was conducted. This study adopted an evidence-based management approach by Barends and Rousseau. The main findings showed that Member States differed in their motivation for collaboration for different pharmaceutical activities. Member States favoured voluntary co-operation for all activities of pricing and reimbursement except for relative effectiveness assessments where Member State authorities had divergent attitudes and prioritised activities related to the sustainability of their healthcare systems and access to medicines. Contrastingly pharmaceutical companies strongly favoured mandatory cooperation for evaluation. Member States motivation for collaboration was highly dependent on the purpose, political will, implementation climate and cultural factors. Currently, with the experiences of ongoing collaborations, following the progress of the discussion at Council, and with a number of inititatives for new pharmaceutical strategy and policy, it is proposed that Member States use their trust, expertise and knowledge of application of evidence-based decision making for pricing and reimbursement of medicines and apply it to decide the future model for Member State collaboration. The applicability of principles of evidence-based management to pharmaceutical policy can be used as a starting point.

Educational Needs of School Nurses Regarding the Evidence-Based Management of Sickle Cell Disease

Sickle cell disease (SCD) is a rare blood disorder that can have life-threatening complications. This presents a challenge for school nurses who may have had limited experience managing complications in the school setting. This study assessed the experience, self-reported knowledge, confidence and ability of school nurses in managing SCD in the school-setting and identified continuing educational needs and preferences. This study used a qualitative, descriptive approach. A survey was previously administered to over 400 school nurses who worked in K-12 schools in Ohio. Those participants who reported experience with managing SCD were invited to participate in a focus group or semi-structured interview. Data were interpreted using thematic analysis strategy. Four overarching themes emerged from the data: (1) perceived lack of support and resources, (2) self-reported lack of knowledge about SCD, (3) importance of partnerships with parents, and (4) need for continuing education and networking with other school nurses. Easily accessible, educational interventions, along with peer networking, can be designed to improve school nurse knowledge and confidence levels in managing SCD. These types of on-demand interventions are important as many school nurses reported infrequent exposure to students with SCD.

Social Behaviour in Zoo Bachelor Groups: A Case Study of Related South American Fur Seals

Simple Summary

Appropriate management of social groups is one of the greatest challenges that face zoos and aquaria worldwide. All-male social groups provide an opportunity for facilities to house surplus males in groups which optimise their welfare whilst they are being retained for future use in breeding programmes. Here, we investigated social behaviour in a relatively poorly studied species, the South American fur seal (SAFS). Four individuals housed in a related group were studied over a 6-month period. The results showed that their social relationships changed over time, although the individuals always engaged in more positive than negative interactions. We recommend establishing baseline social behaviour profiles of individuals to enable long-term monitoring of SAFS social groups, as has been recommended in other species. This will enable enhanced understanding of South American fur seals and will contribute to the development of evidence-based social management guidelines for this species.

Abstract

Appropriate management of social groups is one of the greatest challenges that face zoos and aquaria worldwide. To facilitate breeding programmes, particularly in polygynous species, there is a need to house surplus males in bachelor groups, yet for pinnipeds, the social impact of this management strategy is unknown. The aim of this research was to enhance understanding of sociality in South American fur seals (SAFSs), with a particular focus on social dynamics in a related bachelor group, and consider implications for evidence-based management of this species in zoos. The subjects were four related male seals housed at Bristol Zoo Gardens. Social interaction and nearest neighbour data were collected between February and July 2019. Individuals engaged in both positive and negative social interactions. Positive interactions were more frequent than negative interactions, and no excessive negative interactions were observed. Temporal dynamics were observed in social relationships, and negative interactions did not increase with the onset of the breeding season. Reciprocity in dyadic relationships was variable across the study months, and nearest neighbours were not necessarily reflective of social partners. This research highlights the importance of longitudinal monitoring of social relationships and establishment of baseline social behaviour profiles to support evidence-based species management. We advocate that this research is extended, to further develop our understanding of SAFS social needs within zoo environments, to understand the differences between single-sex and mixed-sex groups and to identify the degree to which the extensive research conducted in other polygynous species (e.g., gorillas) is applicable in the social management of South American fur seals moving forwards.

Behavioral Diversity as a Potential Indicator of Positive Animal Welfare

Modern day zoos and aquariums continuously assess the welfare of their animals and use evidence to make informed management decisions. Historically, many of the indicators of animal welfare used to assess the collection are negative indicators of welfare, such as stereotypic behavior. However, a lack of negative indicators of animal welfare does not demonstrate that an individual animal is thriving. There is a need for validated measures of positive animal welfare and there is a growing body of evidence that supports the use of behavioral diversity as a positive indicator of welfare. This includes an inverse relationship with stereotypic behavior as well as fecal glucocorticoid metabolites and is typically higher in situations thought to promote positive welfare. This review article highlights previous research on behavioral diversity as a potential positive indicator of welfare. Details are provided on how to calculate behavioral diversity and how to use it when evaluating animal welfare. Finally, the review will indicate how behavioral diversity can be used to inform an evidence-based management approach to animal care and welfare.

Understanding Temporal Social Dynamics in Zoo Animal Management: An Elephant Case Study

Zoo animal management procedures which lead to changes to social groups can cause disruption in social hierarchies and the temporary breakdown of social relationships. Animals have different roles in social networks. Understanding individual positions in social networks is important for effective management and ensuring positive welfare for all animals. Using elephants as a case study, the aim of this research was to investigate temporal social dynamics in zoo animals. Behavioural data were collected between January 2016 and February 2017 from 10 African and 22 Asian elephants housed at seven zoos and safari parks in the UK and Ireland. Social interactions were defined as positive physical, positive non-physical, negative physical or negative non-physical. Social network analysis explored social relationships including the fluidity of networks over time and dyadic reciprocity. Social interaction networks were found to be fluid but did not follow a seasonal pattern. Positive interaction networks tended to include the entire social group whereas negative interactions were restricted to specific individuals. Unbalanced ties were observed within dyads, suggesting potential inequalities in relationships. This could impact on individual experiences and welfare. This research highlights subtle temporal dynamics in zoo elephants with the potential for species-level differences. Similar temporal dynamics may also be present in other socially housed zoo species. This research thus provides evidence for the importance of understanding the social networks of zoo animals over longer periods of time. Understanding social networks enables pro-active and evidence-based management approaches. Further research should seek to identify the minimum sampling efforts for social networks in a range of species, to enable the implementation of regular monitoring of social networks and thus improve the welfare of social species under human care.

The use of evidence in decision making by hospital managers in Lebanon: A cross-sectional study

BACKGROUND

Knowledge synthesis products have emerged as support agents for decision making in clinical practice and policy. However, their use for evidence-informed decision making remains limited in health care management especially in low- and middle-income countries. This study assesses the use of evidence by middle and senior managers in Lebanese hospitals.

METHODS

This multihospital cross-sectional study used a self-administered web survey of middle and senior managers. Hospitals were purposively selected, and data were analyzed using descriptive statistics and thematic analysis.

RESULTS

Hospital participation rate was 25%, while adjusted managers' response rate was 44.8%. Prevalence of using evidence was 70%, while prevalence of evidence-seeking behavior was 90%. Evidence was mainly used in design of policies, protocols, and procedures; nursing issues; or procurement decisions. Facilitators for evidence-informed decision making included upper management support and organizational culture, whereas limited resources such as funding, time, and training hindered use of evidence.

CONCLUSIONS

Findings indicate that utilization of evidence was comparable with that of high-income countries. Training and continuous education were crucial for advancing evidence-informed decision making among hospital managers. However, neither the quality nor the sources of evidence used for decision making were assessed in this study. Future studies should assess the quality and sources of evidence utilized in decision making.

The behavioral effects of exhibit size versus complexity in African elephants: A potential solution for smaller spaces

Population-level analyses suggest that habitat complexity, but not necessarily space availability, has important welfare outcomes for elephants in human care. At the Dallas Zoo, the opening of a new exhibit complex allowed us to measure the behavior of two female African elephants across three treatments to evaluate the independent effects of complexity and space. Preoccupancy observations were conducted in the elephants' older exhibit, which consisted of a smaller, more simple yard (630 m² ). Subsequent postoccupancy observations measured behavior in two different spaces in the new exhibit: a larger, complex yard (15,000 m² ), and a smaller, but complex yard (1,520 m² ). The elephants' overall activity levels were greater in complex habitats, regardless of their size. Similar effects of habitat complexity oversize were observed with greater rates of foraging and lower rates of being stationary. Furthermore, elephants were out of view of visitors significantly more in the small, simple yard compared to either of the more complex habitats. However, exhibit size affected the incidence of stereotypic behavior (with lower rates of stereotypy in the larger exhibit compared to the smaller yards) and investigatory behavior (elephants investigated their environments more with increasing size and complexity). Behavioral diversity also increased with exhibit size and complexity. These results indicate that space availability alone is not sufficient to enhance the behavioral welfare of zoo elephants. Therefore, facilities with limited space can still encourage species-appropriate behaviors and improved welfare for the elephants in their care by converting a small, simple area into a more complex habitat.

Nursing Managers' Perspectives on the Facilitators and Barriers to Implementation of Evidence-Based Management

BACKGROUND

Evidence-based health management is defined as a new approach to improve the quality of hospital decisions by systematic application of the best available evidence. To use that, facilitators and barriers to implementation of evidence-based management (EBMgt) in the decision-making process need to be identified.

AIM

The purpose of this study was to assess nursing managers' perspectives on the facilitators and barriers to implementation of EBMgt in Tabriz hospitals, northwest Iran.

METHODS

A cross-sectional study design was used in 2017. The study was conducted in one state in Iran (Tabriz). A total of 276 nursing managers (e.g., matrons, supervisors, & head nurses [HNs]) were invited to participate from the Tabriz hospitals (N = 20); 212 completed and returned the survey, yielding a response rate of 76.81%. The EBMgt assessment questionnaire was used to collect data. The questionnaire consists of two parts. The first part includes barriers to EBMgt (five main domains and 46 questions). The second part includes the facilitators of EBMgt (five main domains and 42 questions). Data entry and analysis were carried out using SPSS-21 software.

RESULTS

Highest mean scores of barriers were observed for "training and research systems" (64.65 ± 12.42). "Lack of communication between knowledge producers and hospital decision-makers" (68.19 ± 17.32) had highest mean scores among all 46 barriers. Also, the results showed that mean scores for all the barriers were higher than 55. The highest mean scores were observed for "social/interpersonal factors" (65.84 ± 17.07). "Interest and willingness to scientific management principles" (68.62 ± 20.17) had highest mean scores among all 42 facilitators.

LINKING EVIDENCE TO ACTION

The aim of EBMgt is to provide the most effective healthcare outcomes. Identifying barriers and facilitators is essential for implementing EBMgt in hospitals. Building the facilitators and eliminating barriers are foundation of EBMgt. Filling the gap between knowledge producers and nursing managers can be a starting point for improvement of the decision-making process in nursing care.

Health system performance assessment in small countries: The case study of Latvia

Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision‐making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence‐based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness.

Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks.

Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country.

As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study.

Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success

In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.

Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings

BACKGROUND

Cardiovascular diseases and diabetes are among the leading causes of premature adult deaths in India. Innovative approaches such as clinical decision support (CDS) software could play a major role in improving the quality of hypertension/diabetes care in primary care settings.

OBJECTIVE

To describe the steps and processes in the development of mWellcare, a complex intervention based on mobile health (mHealth) technology.

METHODS

The Medical Research Council framework was used to develop mWellcare in four steps: (1) identify gaps in usual care through literature review and health facility assessments; (2) identify the components of the intervention through discussions and consultations with experts; (3) develop intervention (clinical algorithms and mHealth system); and (4) evaluate acceptability and feasibility through pilot testing in five community health centers.

RESULTS

Lack of evidence-based, integrated, and systematic management of chronic conditions were major gaps identified. Experts in information technology, clinical fields, and public health professionals identified intervention components to address these gaps. Thereafter, clinical algorithm contextualized to primary care settings were prepared and the mWellcare intervention was developed. During the 2-month pilot, 631 patients diagnosed with hypertension and/or diabetes were registered, with a follow-up rate of 36.2%. The major barrier was resistance to follow mWellcare recommended patient workflow, and to overcome it, we emphasized onsite training and orientation program to cover all health care team member in each CHC.

CONCLUSION

A pilot-tested mWellcare intervention is an mHealth system with important components, i.e. integrated management of chronic conditions, evidence-based CDS, longitudinal health data and automated short-messaging service to reinforce compliance to drug intake and follow-up visit, which will be used by nurses at primary health care settings in India. The effectiveness and cost-effectiveness of the intervention will be tested through a cluster randomized trial (trial registration number NCT02480062).

Study on Hospital Administrators' Beliefs and Attitudes toward the Practice of Evidence-Based Management

The authors' purpose was to explore hospital administrators' beliefs and attitudes toward the practice of evidence-based management (EBMgt) and to identify the needs for EBMgt training programs. A cross-sectional, nonexperimental design was utilized. Survey data were analyzed using descriptive statistics and Spearman's correlation. The results showed that hospital administrators had positive attitudes toward the practice of EBMgt. There was a significant correlation between attitudes and percentage of healthcare management decisions made using an evidence-based practice approach (p < .01). The study findings suggest EBMgt educational training programs would likely help hospital administrators adopt evidence-based practice in management decision-making.

Assessment of Evidence-based Management Training Program: Application of a Logic Model

The purposes of this study were to apply a logic model to plan and implement an evidence-based management (EBMgt) educational training program for healthcare administrators and to examine whether a logic model is a useful tool for evaluating the outcomes of the educational program. The logic model was used as a conceptual framework to guide the investigators in developing an EBMgt educational training program and evaluating the outcomes of the program. The major components of the logic model were constructed as inputs, outputs, and outcomes/impacts. The investigators delineated the logic model based on the results of the needs assessment survey. Two 3-hour training workshops were delivered to 30 participants. To assess the outcomes of the EBMgt educational program, pre- and post-tests and self-reflection surveys were conducted. The data were collected and analyzed descriptively and inferentially, using the IBM Statistical Package for the Social Sciences (SPSS) 22.0. A paired sample t-test was performed to compare the differences in participants' EBMgt knowledge and skills prior to and after the training. The assessment results showed that there was a statistically significant difference in participants' EBMgt knowledge and information searching skills before and after the training (p< 0.001). Participants' confidence in using the EBMgt approach for decision-making was significantly increased after the training workshops (p< 0.001). Eighty-three percent of participants indicated that the knowledge and skills they gained through the training program could be used for future management decision-making in their healthcare organizations. The overall evaluation results of the program were positive. It is suggested that the logic model is a useful tool for program planning, implementation, and evaluation, and it also improves the outcomes of the educational program.

Information Resources for Hospital Administrator Healthcare Management Decision-Making

The purpose of this study was to identify information used by hospital administrators for healthcare management decision-making and what barriers hinder their practice of evidence-based management (EBMgt). A cross-sectional and non-experimental design was utilized. One hundred eight questionnaires were distributed to potential participants. Data analyses were performed using Spearman's correlation. The findings showed that the main resources hospital administrators used for decision-making was organizational data and personal experience. Lack of time was the top barrier to hospital administrators' practice of EBMgt. There was a significant correlation between lack of information searching skills and unfamiliarity with EBMgt (p<0.01) among hospital administrators.

Organizational change tactics: the evidence base in the literature

Planned organizational change processes can be used to address the many challenges facing human service organizations (HSOs) and improve organizational outcomes. There is massive literature on organizational change, ranging from popular management books to academic research on specific aspects of change. Regarding HSOs, there is a growing literature, including increasing attention to implementation science and evidence-based practices. However, research which offers generalizable, evidence-based guidelines for implementing change is not common. The purpose of the authors was to assess the evidence base in this organizational change literature to lay the groundwork for more systematic knowledge development in this important field.