A system dynamics-based simulation study for managing clinical governance and pathways in a hospital

This paper examines the development of clinical pathways in a hospital in Australia based on empirical clinical data of patient episodes. A system dynamics (SD)-based decision support system (DSS) is developed and analyzed for this purpose. System dynamics was used as the simulation modeling tool because of its rigorous approach in capturing interrelationships among variables and in handling dynamic aspects of the system behavior in managing healthcare. The study highlights the scenarios that will help hospital administrators to redistribute caseloads amongst admitting clinicians with a focus on multiple Diagnostic Related Groups (DRG’s) as the means to improve the patient turnaround and hospital throughput without compromising quality patient care. DRG’s are the best known classification system used in a casemix funding model. The classification system groups inpatient stays into clinically meaningful categories of similar levels of complexity that consume similar amounts of resources. Policy explorations reveal various combinations of the dominant policies that hospital management can adopt. The analyses act as a scratch pad for the executives as they understand what can be feasibly achieved by the implementation of clinical pathways given a number of constraints. With the use of visual interfaces, executives can manipulate the DSS to test various scenarios. Experimental evidence based on focus groups demonstrated that the DSS can enhance group learning processes and improve decision making. The simulation model findings support recent studies of CP implementation on various DRG’s published in the medical literature. These studies showed substantial reductions in length of stay, costs and resource utilization

Childhood Obesity: The Role of Health Policy

This first policy report from the CPRC and the NICHQ Childhood Obesity Action Network was released on March 18, 2008 in Miami Florida as part of the Second Childhood Obesity Congress

The Impact of Pre-visit Contextual Data Collection on Patient Activation: Results from a Randomized Control Trial

Background The majority of health indicators are outside of the healthcare system, and current electronic health records (EHR) do not capture those indicators. There is a compelling opportunity to test consumer informatics tools that integrate patient\u27s life circumstances, goals, supports, risks, and care preferences into their EHR for point-of-care discussions. Purpose To determine whether the use of a patient-generated contextual data (PCD) tool designed to enhance the capture and sharing of PCD influenced patient activation. Design, Setting, and Participants A two-armed, non-blind, randomized control trial was conducted between May 2019, and October 2019 at two urban, academically affiliated primary care clinics. 301 patients were enrolled, randomized with stratification by race to study arms. Nearly equal percentages of control and intervention group participants (60.5% vs. 62.4%) and two-thirds of White vs one-third of Black participants completed both assessments (67% vs. 33%). Main outcomes and Measures The main outcome was the pre-/post-visit change in Patient Activation Measure (PAM) score, evaluated using intention-to-treat principles. Analysis was also conducted to determine if patient factors mediated racial differences in baseline PAM scores. Results Using intention-to-treat analysis, there were no significant differences in pre-/post-visit change in PAM scores by arm (p=.079). When allowing for an interaction between race and treatment arm, all interaction terms were not significant (p\u3e0.05). Mediation analysis results indicate income (p=0.025) and difficulty paying monthly bills (p=0.04) when treated as continuous variables, mediated the relationship between race and baseline PAM score. Conclusions and Relevance The findings indicate the PCD Tool did not affect patient activation. Socioeconomic status (SES) mediated baseline racial differences in the PAM score. These data indicate that further study of the relationships among SES and patient activation are needed. The findings also indicate that interventions targeting patient activation need to account for and be sensitive to patient\u27s SES

The Effect of the Implementation of a Quarterly Triad Tool in the Pain Clinic Setting on the Assessment and Mitigation of Risks in Patients on Chronic Opioid Therapy

The concurrent use of opioids and benzodiazepines (BZDs poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs have a defined increase in rates of adverse events, overdose, and death, warranting close monitoring. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documenting medical necessity, and e adjusting treatment in response to clinical changes are essential. National and state guidelines recommend that patients on chronic opioid therapy (COT) should periodically undergo urine drug testing and a review of prescription drug monitoring program to confirm adherence to the treatment plan. These guidelines also recommend reviewing the prevalence and pharmacologic consequences of BZDs among patients on COT. This DNP Project evaluated the effectiveness of the implementation of a quarterly triad tool (QTT), which included (a) current urine drug testing and (b) prescription drug monitoring, with (c) the addition of medication reconciliation for concomitant BZD use (CBU) on mitigation of adverse event risks in patients treated for chronic pain in a pain clinic in central Indiana. One of six providers did not adopt the practice change; but 151 of 154 patients were screened using the QTT, and 24 (15.89%) had CBU detected. Documentation of risk education increased from 25% pre-intervention to 100% post-intervention (X2(1) = 10.59, p = .001). Follow-up plan documentation also increased to a statistically significant level: 5% pre-intervention to 75% post-intervention (X2(1) = 8.24, p = .004)

The Effect of the Implementation of a Quarterly Triad Tool in the Pain Clinic Setting on the Assessment and Mitigation of Risks in Patients on Chronic Opioid Therapy

The concurrent use of opioids and benzodiazepines (BZDs poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs have a defined increase in rates of adverse events, overdose, and death, warranting close monitoring. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documenting medical necessity, and e adjusting treatment in response to clinical changes are essential. National and state guidelines recommend that patients on chronic opioid therapy (COT) should periodically undergo urine drug testing and a review of prescription drug monitoring program to confirm adherence to the treatment plan. These guidelines also recommend reviewing the prevalence and pharmacologic consequences of BZDs among patients on COT. This DNP Project evaluated the effectiveness of the implementation of a quarterly triad tool (QTT), which included (a) current urine drug testing and (b) prescription drug monitoring, with (c) the addition of medication reconciliation for concomitant BZD use (CBU) on mitigation of adverse event risks in patients treated for chronic pain in a pain clinic in central Indiana. One of six providers did not adopt the practice change; but 151 of 154 patients were screened using the QTT, and 24 (15.89%) had CBU detected. Documentation of risk education increased from 25% pre-intervention to 100% post-intervention (X2(1) = 10.59, p = .001). Follow-up plan documentation also increased to a statistically significant level: 5% pre-intervention to 75% post-intervention (X2(1) = 8.24, p = .004)

A Multimodal Analgesic Virtual Reality Program to Reduce Opioid Exposure

The opioid crisis continues to be a public health concern. Traditionally, an opioid-centric approach treats postoperative pain. The following PICOT question guided this project: Will initiating a multimodal analgesic virtual reality quality improvement program (I) compared to current practice (C) decrease opioid requirements (O) in robotic hysterectomy patients (P) during the postoperative period (T)? Several articles promote non-opioid analgesia and non-pharmacological interventions, such as multimodal analgesia and virtual reality (VR) for pain management. This project reviewed pre- and post-implementation data after implementing new evidence-based multimodal analgesia and VR protocols. The project captured a total of 64 patients in the pre-implementation group. A total of 22 patients received both multimodal analgesia and VR in the post-implementation group. There was no statistically significant difference in total opioid consumption converted as morphine milligram equivalents (MME) between the pre-implementation and post-implementation groups. However, there was a statistically significant difference in multimodal analgesia administered in Pre-op between the pre-implementation and post-implementation groups. In conclusion, the execution of the multimodal analgesic VR program allowed for nursing adoption of novel evidence-based practices (EBP) and promoted the use of non-opioid and non-pharmacological interventions. Although the combination of multimodal analgesia and VR did not reduce opioid consumption, the practice of incorporating multimodal analgesia as a standard workflow improved

Evidence-based implementation practices applied to the intensive treatment of eating disorders: Summary of research and illustration of principles using a case example

Implementation of evidence‐based practices (EBPs) in intensive treatment settings poses a major challenge in the field of psychology. This is particularly true for eating disorder (ED) treatment, where multidisciplinary care is provided to a severe and complex patient population; almost no data exist concerning best practices in these settings. We summarize the research on EBP implementation science organized by existing frameworks and illustrate how these practices may be applied using a case example. We describe the recent successful implementation of EBPs in a community‐based intensive ED treatment network, which recently adapted and implemented transdiagnostic, empirically supported treatment for emotional disorders across its system of residential and day‐hospital programs. The research summary, implementation frameworks, and case example may inform future efforts to implement evidence‐based practice in intensive treatment settings.Published versio

Review: Self-management Support Program on Dietary Behaviors in Patients with Type 2 Diabetes Mellitus

Background: Dietary behaviors are the cornerstone in diabetes management. Diabetes self-management support program in which patients play an active role to determine their health care is an important strategy to improve dietary behaviors in type 2 diabetes mellitus (T2DM) patients. Its elements which contribute to the successfulness of the program need to be identified.Purpose: To review and identify the elements of self-management support program to improve dietary behaviors in T2DM patients.Method: An integrative review was conducted. Relevant studies published in English language during last 10-year, measured dietary behaviors in T2DM patients, and retrieved from CINAHL and PubMed were included.Results: 13 experimental studies and 3 meta-analysis studies were reviewed. Goal setting and action planning combined with other strategies (brief counseling and problem solving) seemed more effective to improve dietary behaviors. Either trained lay people or clinicians could lead the program although clinician-led programs were common. Contents and materials of the education vary across the studies. The effects on dietary behaviors could be detected in short term duration of program (<6 months). Continuing follow-up was essential element which face-to-face follow-up as the most common strategy. The utilization of technology such as telephone-call and internet based follow-up might provide more benefits for patients.Conclusion: Diabetes self-management support program is effective to improve dietary behaviors in T2DM patients. Further research is needed to test the effectiveness of goal setting strategy and technology utilization for follow-up strategy such telephone call in Indonesian T2DM population

Achieving change in primary care—causes of the evidence to practice gap : systematic reviews of reviews

Acknowledgements The Evidence to Practice Project (SPCR FR4 project number: 122) is funded by the National Institute of Health Research (NIHR) School for Primary Care Research (SPCR). KD is part-funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Research and Care West Midlands and by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR. This paper presents independent research funded by the National Institute of Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Funding This study is funded by the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR).Peer reviewedPublisher PD