Systematic review of economic evaluations and cost analyses of guideline implementation strategies

Objectives To appraise the quality of economic studies undertaken as part of evaluations of guideline implementation strategies; determine their resources use; and recommend methods to improve future studies. Methods Systematic review of economic studies undertaken alongside robust study designs of clinical guideline implementation strategies published (1966-1998). Studies assessed against the BMJ economic evaluations guidelines for each stage of the guideline process (guideline development, implementation and treatment). Results 235 studies were identified, 63 reported some information on cost. Only 3 studies provided evidence that their guideline was effective and efficient. 38 reported the treatment costs only, 12 implementation and treatment costs, 11 implementation costs alone, and two guideline development, implementation and treatment costs. No study gave reasonably complete information on costs. Conclusions Very few satisfactory economic evaluations of guideline implementation strategies have been performed. Current evaluations have numerous methodological defects and rarely consider all relevant costs and benefits. Future evaluations should focus on evaluating the implementation of evidence based guidelines. Keywords: Cost-effectiveness analysis, physician (or health care professional) behaviour, practice guidelines, quality improvement, systematic review.Peer reviewedAuthor versio

A pragmatic cluster randomised trial evaluating three implementation interventions

Background Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting. Methods A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients' experiences, and stakeholders' experiences of implementation, including influences. ANOVA was used to test differences over time and interventions. Results Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility. Conclusions This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions' impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance. Trial registration ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE

Automated Measurement of Adherence to Traumatic Brain Injury (TBI) Guidelines using Neurological ICU Data

Using a combination of physiological and treatment information from neurological ICU data-sets, adherence to traumatic brain injury (TBI) guidelines on hypotension, intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is calculated automatically. The ICU output is evaluated to capture pressure events and actions taken by clinical staff for patient management, and are then re-expressed as simplified process models. The official TBI guidelines from the Brain Trauma Foundation are similarly evaluated, so the two structures can be compared and a quantifiable distance between the two calculated (the measure of adherence). The methods used include: the compilation of physiological and treatment information into event logs and subsequently process models; the expression of the BTF guidelines in process models within the real-time context of the ICU; a calculation of distance between the two processes using two algorithms (“Direct” and “Weighted”) building on work conducted in th e business process domain. Results are presented across two categories each with clinical utility (minute-by-minute and single patient stays) using a real ICU data-set. Results of two sample patients using a weighted algorithm show a non-adherence level of 6.25% for 42 mins and 56.25% for 708 mins and non-adherence of 18.75% for 17 minutes and 56.25% for 483 minutes. Expressed as two combinatorial metrics (duration/non-adherence (A) and duration * non-adherence (B)), which together indicate the clinical importance of the non-adherence, one has a mean of A=4.63 and B=10014.16 and the other a mean of A=0.43 and B=500.0

Maximising Social Interactions and Effectiveness within Distance Learning Courses: Cases from Construction

Advanced Internet technologies have revolutionised the delivery of distance learning education. As a result, the physical proximity between learners and the learning providers has become less important. However, whilst the pervasiveness of these technological developments has reached unprecedented levels, critics argue that the student learning experience is still not as effective as conventional face-to-face delivery. In this regard, surveys of distance learning courses reveal that there is often a lack of social interaction attributed to this method of delivery, which tends to leave learners feeling isolated due to a lack of engagement, direction, guidance and support by the tutor. This paper defines and conceptualises this phenomenon by investigating the extent to which distance-learning programmes provide the social interactions of an equivalent traditional classroom setting. In this respect, two distance learning case studies were investigated, covering the UK and Slovenian markets respectively. Research findings identified that delivery success is strongly dependent on the particular context to which the specific distance learning course is designed, structured and augmented. It is therefore recommended that designers of distance learning courses should balance the tensions and nuances associated with commercial viability and pedagogic effectiveness

Study Protocol: A Randomized Controlled Trial of Patient Navigation-Activation to Reduce Cancer Health Disparities

Abstract Background Cancer health disparities affecting low-income and minority patients are well documented. Root-causes are multifactorial, including diagnostic and treatment delays, social and financial barriers, and poor communication. Patient navigation and communication coaching (activation) are potential interventions to address disparities in cancer treatment. The purpose of this clinical trial is to test the effectiveness of an intervention combining patient navigation and activation to improve cancer treatment. Methods/Design The Rochester Patient Navigation Research Program (PNRP) is a National Cancer Institute-sponsored, patient-level randomized trial (RCT) of patient navigation and activation, targeting newly-diagnosed breast and colorectal cancer patients in Rochester, NY. The goal of the program is to decrease cancer health disparities by addressing barriers to receipt of cancer care and promoting patient self-efficacy. The intervention uses trained, paraprofessional patient navigators recruited from the target community, and a detailed training and supervisory program. Recruited patients are randomly assigned to receive either usual care (except for baseline and follow-up questionnaires and interviews) or intervention. The intervention patients receive tailored assistance from their patient navigators, including phone calls, in-person meetings, and behind-the-scenes coordination of care. A total of 344 patients have been recruited. Outcomes measured at three month intervals include timeliness of care, patient adherence, patient satisfaction, quality of life, self-efficacy, health literacy, and cancer knowledge. Discussion This unique intervention combining patient navigation and patient activation is designed to address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of patient navigation programs. Trials Registration clinicaltrials.gov identifier NCT00496678http://deepblue.lib.umich.edu/bitstream/2027.42/78254/1/1471-2407-10-551.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78254/2/1471-2407-10-551.pdfPeer Reviewe

Maximising social interactions and effectiveness within distance learning courses : cases from construction

Advanced Internet technologies have revolutionised the delivery of distance learning education. As a result, the physical proximity between learners and the learning providers has become less important. However, whilst the pervasiveness of these technological developments has reached unprecedented levels, critics argue that the student learning experience is still not as effective as conventional face-to-face delivery. In this regard, surveys of distance learning courses reveal that there is often a lack of social interaction attributed to this method of delivery, which tends to leave learners feeling isolated due to a lack of engagement, direction, guidance and support by the tutor. This paper defines and conceptualises this phenomenon by investigating the extent to which distance-learning programmes provide the social interactions of an equivalent traditional classroom setting. In this respect, two distance learning case studies were investigated, covering the UK and Slovenian markets respectively. Research findings identified that delivery success is strongly dependent on the particular context to which the specific distance learning course is designed, structured and augmented. It is therefore recommended that designers of distance learning courses should balance the tensions and nuances associated with commercial viability and pedagogic effectiveness

Conversational Agents, Humorous Act Construction, and Social Intelligence

Humans use humour to ease communication problems in human-human interaction and \ud in a similar way humour can be used to solve communication problems that arise\ud with human-computer interaction. We discuss the role of embodied conversational\ud agents in human-computer interaction and we have observations on the generation\ud of humorous acts and on the appropriateness of displaying them by embodied\ud conversational agents in order to smoothen, when necessary, their interactions\ud with a human partner. The humorous acts we consider are generated spontaneously.\ud They are the product of an appraisal of the conversational situation and the\ud possibility to generate a humorous act from the elements that make up this\ud conversational situation, in particular the interaction history of the\ud conversational partners

The Value of Information Technology-Enabled Diabetes Management

Reviews different technologies used in diabetes disease management, as well as the costs, benefits, and quality implications of technology-enabled diabetes management programs in the United States