4,569 research outputs found

    The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

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    Background: Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed. Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully. Methods: We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist. Results: We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy. Conclusions: The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed

    Characteristics and impact of interventions to support healthcare providers’ compliance with guideline recommendations for breast cancer: a systematic literature review

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    BackgroundBreast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.MethodsWe searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.ResultsWe identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.ConclusionsDifferent types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation

    Organizational interventions to implement improvements in patient care: a structured review of reviews

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    BACKGROUND: Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement. OBJECTIVE: To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care. DESIGN: Structured review of published reviews of rigorous evaluations. DATA SOURCES: Published reviews of studies on organizational interventions. REVIEW METHODS: Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003. Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings. RESULTS: A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain. CONCLUSION: There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty

    Impact of implementing a computerised quality improvement intervention in primary healthcare

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    Health systems worldwide experience large evidence practice gaps with underuse of proven therapies, overuse of inappropriate treatments and misuse of treatments due to medical error. Quality improvement (QI) initiatives have been shown to overcome some of these gaps. Computerised interventions, in particular, are potential enablers to improving system performance. However, implementation of these interventions into routine practice has resulted in mixed outcomes and those that have been successfully integrated into routine practice are difficult to sustain. The objective of this thesis is to understand how a multifaceted, computerised QI intervention for cardiovascular disease (CVD) prevention and management was implemented in Australian general practices and Aboriginal Community Controlled Health Services and assess the implications for scale-up of the intervention. The intervention was implemented as part of a large cluster-randomised controlled trial, the TORPEDO (Treatment of Cardiovascular Risk using Electronic Decision Support) study. The intervention was associated with improved guideline recommended cardiovascular risk factor screening rates but had mixed impact on improving medication prescribing rates. In this thesis, I designed a multimethod process and economic evaluation of the TORPEDO trial. The aims were to: i. Develop a theory-informed logic model to assist in the design of the overall evaluation to address study aims (Chapter 3). ii. Conduct a post-trial audit to quantify changes in cardiovascular risk factor screening and prescribing to high risk patients over an 18-month post-trial period and understand the impact of the intervention outside of a research trial setting (Chapter 4). vi iii. Use normalisation process theory to identify the underlying mechanisms by which the intervention did and did not have an impact on trial outcomes (Chapter 5). iv. Use video ethnography to explore how the intervention was used and cardiovascular risk communicated between patients and healthcare providers (Chapter 6). v. Conduct an economic evaluation to inform policy makers for delivering the intervention at scale through Primary Health Networks in New South Wales (Chapter 7). vi. Use a new theory to explain the factors that drove adoption and non-adoption of the intervention and assess what modifications may be needed to promote spread and scale-up (Chapter 8). I found variable outcomes during the post-trial period with a plateauing of improvements in guideline recommended screening practices but an ongoing improvement in prescribing to high risk patients. The group that continued to have the most benefit was patients at high CVD risk who were not receiving recommended medications at baseline. The delay in prescribing recommended medication suggests healthcare providers adopt a cautious approach when introducing new treatments. Six intervention primary healthcare services participated as case studies for the process evaluation. Qualitative and quantitative data sources were combined at each primary healthcare service to enable a detailed examination of intervention implementation from multiple perspectives. The process evaluation identified the complex interaction between several underlying mechanisms that influenced the implementation processes and explained the mixed trial outcomes: (1) organisational mission; (2) leadership; (3) the role of teams; (4) technical competence and dependability of the software tools. Further, there were different ‘active ingredients’ vii necessary during the initial implementation compared to those needed to sustain use of the intervention. In the video ethnography and post-consultation patient interviews, important insights were gained into how the intervention was used, and its interpretation by the doctor and patient. Through ethnographic accounts, the doctor’s communication of cardiovascular risk was not sufficient in engaging patients and having them act upon their high-risk status; effective communication required interactions be assessed, discussed and negotiated. The economic evaluation identified the cost implications of implementing the intervention as part of a Primary Health Network program in the state of New South Wales, Australia; and modelled data looked at the impact of small but statistically significant reductions in clinical risk factors based on the trial data. When scaled to a larger population the intervention has potential to prevent major CVD events at under AU$50,000 per CVD event averted largely due to the low costs of implementing the intervention. However, the clinical risk factor reductions were small and a stronger case for investment would be made if the effects sizes could be enhanced and sustained over time. The findings from chapters 4-6 provide insight into the intricacy of the barriers influencing implementation processes and adoption of the intervention. Taken together, these studies provide a detailed explanation of the processes that may be required to implement such an intervention at scale and the factors that might influence its impact and sustainability. The findings are expected to assist policy makers, administrators and health professionals in developing multiple interdependent QI strategies at the organisational, provider and consumer levels to improve primary healthcare system performance for cardiovascular disease management and prevention

    Effective dissemination: An examination of the costs of implementation strategies for the AOD field.

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    This document is Part Two of a 3-part series by the National Centre for Education and Training on Addiction (NCETA) examining the effectiveness, costs and theories related to dissemination and implementation of research into practice. Part One is a systematic literature review that evaluated the effectiveness of 16 different dissemination strategies for facilitating the implementation of new research, programs and treatments to improve outcomes for clients with alcohol and other drug-related problems. Part Two involves an examination of the costs associated with using such strategies, and Part Three is an examination of the theories and models of change underlying the use of strategies. In this Part, the costs of implementing innovations and the implications of using dissemination strategies for the alcohol and other drug (AOD) field are examined. Part One in this series is a systematic review of the effectiveness of dissemination and implementation strategies (Bywood, Lunnay, & Roche, 2008). However, evidence related to economic considerations was not based on a systematic search using relevant terms associated with economic analysis. Rather, it is a summary of the evidence from the systematic review on effectiveness that also contained data on costs of using an implementation strategy. All studies in Part One that showed evidence that a particular strategy was effective in changing practitioners’ behaviour or improving organisational efficiency were scrutinised to determine whether an economic analysis had also been undertaken. These studies then formed the evidence base for the present report. An implementation strategy can be effective, without being cost-effective. Thus, from an economic perspective, the key question is whether certain dissemination and implementation activities involve a more efficient use of limited resources compared to other activities. The key research questions for this study were: 1. What are the economic considerations for the use of effective dissemination and implementation strategies? 2. Which implementation strategies provide an efficient and cost-effective means by which to facilitate uptake of innovations by the AOD field? The key findings from this review are: • CME was generally effective and cost-effective, although formats differed substantially • Educational outreach showed mixed results on cost-effectiveness • Educational materials were relatively cheap, but had little effectiveness • Multi-faceted approaches differed substantially in context and content, making it difficult to make meaningful comparisons on the basis of cost • The evidence base of studies containing good quality economic analyses was limited (only 9 of the 16 strategies were evaluated for costs) • Studies that reported on costs of implementation strategies were heterogeneous, reporting of details and quality of methodology was poor, and data collection was incomplete • Few studies evaluated costs of implementation strategies in the AOD field • There is a need for future evaluation studies to examine efficiency through use of economic evaluation

    Implementation of Hypertension Clinical Practice Guidelines: A Systematic Review of Strategies to Change Physician Behavior and Improve Patient Outcomes

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    Background: Hypertension remains a major cause of cardiovascular disease morbidity and mortality worldwide. There is strong evidence that blood pressure control is associated with significant reduction in morbidity and mortality caused by cardiovascular events. However, only one-third of Americans with hypertension have adequate blood pressure control. Clinical practice guidelines have been established to guide physician treatment of hypertension, yet many physicians do not follow these guidelines. In response to this problem, there is a growing body of literature regarding interventions designed to help physicians adhere to hypertension clinical practice guidelines. Objectives: To systematically identify, appraise and synthesize studies of professional educational or quality assurance interventions designed to improve physician adherence to hypertension clinical practice guidelines. The effectiveness of various intervention strategies in changing physician behavior and improving patient outcomes will be evaluated. Research design: I performed a systematic review of studies published in MEDLINE between 1966 and 2005 describing interventions to improve physician adherence to hypertension guidelines in primary care. Randomized controlled trials, cohort studies, case control studies and time-series analyses describing physician targeted educational or quality assurance interventions with objective measures of physician hypertension management behavior or patient blood pressure outcomes were included. Data from each study was abstracted in to evidence tables for review and all studies were assigned a quality grade based (good, fair, poor) based on their study design and potential for selection bias, measurement bias, and confounding. Results: The initial Medline search yielded 574 citations of which 32 were included in this review. Three citations additional were identified through manual searching, These studies examined the following interventions: educational outreach (n=12), local opinion leaders (n=5), audit and feedback (n=16), decision support (n=5), reminders (n=11), and local consensus development (n=4). Interventions involving Educational Outreach, especially when combined with Local Opinion Leader and Audit and Feedback, resulted in moderate changes in prescribing behavior and small increases in blood pressure control. No studies examined the independent effects of educational outreach or local opinion leaders, but audit and feedback appeared to have no effect on its own. Interventions involving Reminders were highly effective in increasing screening and prescribing, but did not reduce blood pressure; while decision support was generally ineffective on its own. Local Consensus Development of Guidelines had moderate to large effects on prescribing behavior and had mixed results on blood pressure control. Conclusions: No single educational or quality assurance intervention is superior to others in improving physician adherence to hypertension guidelines, although several interventions appear to be ineffective or untested on their own. Multifaceted Interventions especially those involving Educational Outreach by Local Opinion Leaders, Audit and Feedback, Local Consensus Guideline Development and/or Reminders appear to be the most promising physician oriented interventions to improve patient blood pressure control.Master of Public Healt

    A Multifaceted Approach to Improving Sedation Practices in the Cardiovascular Intensive Care Unit

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    Purpose: Sedation protocols have been positively correlated with improved patient outcomes in the intensive care unit (ICU). Therefore, healthcare leaders should direct efforts to improving protocol compliance through evidence-based strategies. The purpose of this study was to evaluate the impact of a multifaceted intervention, consisting of educational outreach, point of care (POC) reminders, and audit and feedback (A&F), on nurse compliance with an ICU sedation protocol. A secondary data analysis was performed to evaluate the impact of the intervention on patient outcomes. Methods: This was a before/after comparative analysis. A Research Electronic Data Capture (REDCap) pre-survey (n=58) was distributed to cardiovascular intensive care unit (CVICU) nurses (n=139) via a modified email listserv. An educational PowerPoint session via Zoom was delivered to staff during two non-mandatory unit council meetings. A modified post-survey evaluated (n=43) was distributed to nurses who completed the pre-test and attended at least one of the educational sessions. The post-survey evaluated the impact of the educational session on nursing knowledge, attitudes, and perceived barriers to protocol utilization. A series of multiple-choice questions were incorporated in the survey to evaluate nursing knowledge of evidence-based guidelines and protocol components. Attitudes were scored using an attitude-specific component of the Nurse Sedation Practices Scale (NSPS). Barriers were identified through true or false, multiple response, or open response questions. A secondary multifaceted intervention was implemented over three months to improve sedation protocol compliance and patient-related health outcomes. Sedation practices, mechanical ventilator (MV) duration, delirium, and reintubations were compared before (n=92) and after (n=82) the intervention by performing a retrospective chart review. Results: There was a significant improvement in knowledge scores and NSPS scores post- educational intervention (p Conclusion: This study demonstrated the positive impact of a multifaceted educational approach on nursing knowledge and attitudes regarding an evidence-based sedation protocol. Furthermore, this study suggests that a multifaceted intervention may improve quality of care by reducing MV duration. Future research should focus on applying this strategy to vulnerable populations who are susceptible to prolonged MV. Furthermore, future research should evaluate strategies to improve the feasibility of this approach
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