Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline

Background Clinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes. Methods The TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control (with usual care and no TDFI). The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou’s modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment (ROI) was also calculated. Results Following intervention implementation, the use of pH first line increased significantly across intervention hospitals [risk ratio (95% CI) ranged from 3.1 (1.14 to8.43) p < .05, to 8.14 (3.06 to21.67) p < .001] compared to the control hospital, which remained unchanged [risk ratio (CI) = .77 (.47-1.26) p = .296]. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years. Conclusion The TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice

The economic value of empowering older patients transitioning from hospital to home: Evidence from the 'Your Care Needs You' intervention

Hospital-to-home transitions are a critical component of effective healthcare delivery, especially for patients aged 75 and older. This study evaluates the cost-effectiveness of the 'Your Care Needs You' (YCNY) intervention, a patient-centred approach designed to empower older adults during discharge, compared to standard care. The analysis adopts the perspective of the National Health Service (NHS) and Personal Social Services. Data were drawn from a cluster randomised controlled trial (cRCT) conducted within the UK NHS over a 90-day post-discharge follow-up period. Adjusted differences in costs and Quality-Adjusted Life Years (QALYs) were estimated using Multilevel Mixed-Effects Generalised Linear Models (MME-GLM) to account for the hierarchical structure of the trial design. Alternatively, Seemingly Unrelated Regression (SUR) models were employed to address potential correlations between costs and QALYs. Scenario analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the results. The YCNY intervention reduced costs by {\pounds}269 and achieved a QALY gain of 0.0057, resulting in a net health benefit (NHB) of 0.0246 at a {\pounds}15,000/QALY threshold. It demonstrated an 89% probability of cost-effectiveness compared to standard care within the trial's time horizon. Findings remained robust across alternative scenarios and sensitivity analyses. These results suggest that YCNY is a promising and potentially cost-effective strategy for improving hospital-to-home transitions for older adults. By enhancing outcomes and reducing costs, the study supports integrating patient-centred interventions like YCNY into routine NHS practice, with the potential to improve both efficiency and quality of healthcare delivery

Evaluating an intervention to improve the safety and experience of transitions from hospital to home for older people (Your Care Needs You) : a protocol for a cluster randomised controlled trial and process evaluation

Background Older patients often experience safety issues when transitioning from hospital to home. The ‘Your Care Needs You’ (YCNY) intervention aims to support older people to‘know more’ and‘do more’ whilst in hospital so that they are better prepared for managing at home. Methods A multi-centre cluster randomised controlled trial (cRCT) will evaluate the efectiveness and cost-efectiveness of the YCNY intervention. Forty acute hospital wards (clusters) in England from varying medical specialities will be randomised to deliver YCNY or care-as-usual on a 1:1 basis. The primary outcome will be unplanned hospital readmission rates within 30 days of discharge. This will be extracted from routinely collected data of at least 5440 patients (aged 75 years and older) discharged to their own homes during the 4- to 5-month YCNY intervention period. A nested cohort of up to 1000 patients will be recruited to the study to collect secondary outcomes via follow-up questionnaires at 5-, 30-and 90-day post-discharge. These will include measures of patient experience of transitions, patient-reported safety events, quality of life and healthcare resource use. Unplanned hospital readmission rates at 60 and 90 days of discharge will be collected from routine data. A process evaluation (primarily interviews and observations with patients, carers and staff) will be conducted to understand the implementation of the intervention and the contextual factors that shape this, as well as the inter- vention’s underlying mechanisms of action. Fidelity of intervention delivery will also be assessed across all intervention wards

The assessment of physiotherapy practice is a robust measure of entry-level physiotherapy standards : Reliability and validity evidence from a large, representative sample

The Assessment of Physiotherapy Practice (APP) is a 20-item assessment instrument used to assess entry-level physiotherapy practice in Australia, New Zealand and other international locations. Initial APP reliability and validity evidence supported a unidimensional or single latent factor as the best representation of entry-level physiotherapy practice performance. However, there remains inconsistency in how the APP is interpreted and operationalised across Australian and New Zealand universities offering entry-level physiotherapy programs. In essence, the presumption that the psychometric integrity of the APP generalises across people, time, and contexts remains largely untested. This multi-site, archival replication study utilised APP assessment data from 8,979 clinical placement assessments, across 19 Australian and New Zealand universities, graduating entry-level physiotherapy students (n=1865) in 2019. Structural representation of APP scores were examined via confirmatory factor analysis and penalised structural equation models. Factor analyses indicated a 2-factor representation, with four items (1–4) for the professional dimension and 16 items (5–20) for the clinical dimension, is the best approximation of entry-level physiotherapy performance. Measurement invariance analyses supported the robustness of this 2-factor representation over time and across diverse practice areas in both penultimate and final years of study. The findings provide strong evidence for the psychometric integrity of the APP, and the 2-factor alternative interpretation and operationalisation is recommended. To meet entry-level standards students should be assessed as competent across both professional and clinical dimensions of physiotherapy practice

Improving the safety and experience of transitions from hospital to home:a cluster randomised controlled trial of an intervention to involve older people in their care (Your Care Needs You)

BACKGROUND: Transitions from hospital to home are risky for older people. The role of patient involvement in supporting safe transitions is unclear. OBJECTIVE: To assess the clinical effectiveness of an intervention to improve the safety and experience of care transitions for older people. TRIAL DESIGN: Cluster randomised controlled trial. PARTICIPANTS: Eleven National Health Service acute hospital trusts and 42 wards (clusters) routinely providing care for older people (aged 75 years and older) planning to transition back home. INTERVENTION: Patient involvement ward-level intervention-Your Care Needs You (YCNY). OUTCOMES: Unplanned hospital readmission rates within 30 days of discharge (primary outcome). Secondary outcomes included readmissions at 60 and 90 days post-discharge, experience of transitions and safety events. RANDOMISATION: Ward as the unit of randomisation from varying medical specialities randomised to YCNY or care-as-usual on a 1:1 basis. BLINDING: Ward staff, research nurses and researchers were unblinded. Patients were unaware of treatment allocation. Statisticians were blinded to the primary outcome data until statistical analysis plan sign-off. RESULTS: Using a mixed effects logistic regression we saw no significant difference in unplanned 30-day readmission rates (OR 0.93; 95% CI, 0.78 to 1.10; P = .372) between intervention (17%) and control (19%). At all timepoints, rates were lower in the intervention group. The total number of readmissions was lower in the intervention group (all timepoints) reaching statistical significance across 90-days with 13% fewer readmissions (IRR: 0.87; 95% CI 0.76 to 0.99) than the control. At 30-days only, intervention group patients reported better experiences of transitions and significantly fewer safety events. Serious adverse events were similarly observed in both groups [YCNY: 26 (52.0%), Care-as-usual: 24 (48.0%)]. None related to treatment. CONCLUSIONS: YCNY did not significantly impact on unplanned hospital readmissions at 30 days but in some secondary outcomes we did find evidence of clinical benefit

Improving older people’s experiences and safety at transitions of care:the PACT mixed-methods study including RCT

Background: Transitions from hospital to home are a risky time for older people (aged 75 years and older). Unplanned and often avoidable hospital re-admissions are therefore high in this group. This research aimed to understand if increased involvement of older people in their care in hospital would improve the safety and experience of care transitions. Objectives: In six work packages we set out to: 1. understand patient and carer involvement in and experience of care transitions 2. explore staff experiences of delivering good transitional care 3. develop and validate a new measure (the Partners at Care Transitions Measure) to assess patient experience and safety during care transitions 4. create a theory and logic model to inform the co-designed transitions intervention followed by a formative evaluation 5. test the feasibility of delivering a trial to evaluate the intervention 6. evaluate the clinical-and cost-effectiveness of the transitions intervention with a parallel process evaluation. Design: Qualitative methods (1 and 2), literature reviewing, Delphi techniques and validation testing (3), co-design (4), cluster feasibility trial (5) and cluster randomised controlled trial (6). Settings: National Health Service acute hospital trusts, general practices, patients and carer homes across the north of England, United Kingdom. Participants: Patients aged 75 years and older and their caregivers. National Health Service staff working in acute National Health Service trusts on wards delivering the intervention. Intervention: ‘Your Care Needs You’ intervention to support patient and carer involvement in hospital care in preparation for returning home. This comprised fixed components: a booklet, an advice sheet for managing at home and a film; and flexible components: ongoing staff involvement of patients through multiple approaches. Implementation included a nominated lead, staff training and posters. Main outcome measures: Primary outcome was unplanned 30-day hospital re-admissions. Secondary outcomes included: unplanned 60-and 90-day hospital re-admissions; quality of transition; health-related quality of life (EuroQol-5 Dimensions, five-level version); and self-reported healthcare resource use. Data sources: National Health Service Secondary Use Services data and Hospital Episodes data for work package 2 and routinely recorded National Health Service acute trust hospital data on re-admissions for work packages 5 and 6. Review methods: Systematic narrative review for preparatory work on patient involvement; narrative meta review of transitions interventions; scoping review of transitions measures. Results: Work package 1: Six themes relating to patient experience of care transitions. Patient involvement in hospital care found to be challenging ‘work’ that was often invisible to staff. Work package 2: National Health Service staff reported that high-quality care transitions were facilitated primarilythrough trust and strong relationships. Work package 3: A measure of quality and safety of care transitions (Partners at Care Transitions Measure) developed and validated with good internal reliability and internal consistency. Work package 4: An intervention called ‘Your Care Needs You’ that required revisions to support implementation. Work package 5: Primary outcome data were collected for 90% of participants. Follow-up questionnaire responserates were lower than anticipated (75% vs. 85%). Information on the acceptability, usability and implementation of the intervention informed iterations to the intervention and implementation package. Work package 6: 4947 participants from 39 hospital wards took part in the main trial. Six hundred and thirteen participants from 35 wards took part in the nested cohort. No differences were observed in the primary outcome of unplanned re-admission (Y/N) at 30 days post discharge [17% experienced re-admission within 30 days in the ‘Your Care Needs You’ group, 18% in care-as-usual, odds ratio: (0.93; 95% confidence interval, 0.78 to 1.10; p = 0.372)], and also at 60 and 90 days post discharge but all results were in favour of the intervention with a reduction in total re-admissions of 13% over 90 days [incidence rate ratio: 0.87 (0.76 to 0.99), p = 0.039]. There was a statistically significant reduction in Partners at Care Transitions Measure safety concerns at 30 days post discharge. The intervention is likely to be cost-effective. Limitations: The main trial was conducted during the COVID-19 pandemic which exacerbated staffing challenges and limited opportunities to enhance and support implementation of the intervention. Participant recruitment to the nested study was challenging, resulting in fewer patients than planned and a less diverse sample than that included in the primary cohort. Therefore, while our primary cohort is representative of the patients in the hospital during the trial period, the nested cohort may suffer from some bias. Conclusions: The ‘Your Care Needs You’ intervention offers a way to support staff and patients/families to facilitate greater involvement in care. This research demonstrates that increased involvement in hospital care has the potential to improve safety at transitions. Finding ways to support staff to encourage better patient involvement could lead to even more benefits being realised

Electrochemical insights into the mechanism of NiFe membrane-bound hydrogenases

Hydrogenases are enzymes of great biotechnological relevance because they catalyse the interconversion of H2, water (protons) and electricity using non-precious metal catalytic active sites. Electrochemical studies into the reactivity of NiFe membrane-bound hydrogenases (MBH) have provided a particularly detailed insight into the reactivity and mechanism of this group of enzymes. Significantly, the control centre for enabling O2 tolerance has been revealed as the electron-transfer relay of FeS clusters, rather than the NiFe bimetallic active site. The present review paper will discuss how electrochemistry results have complemented those obtained from structural and spectroscopic studies, to present a complete picture of our current understanding of NiFe MBH

Construction and analysis of Hydrogeological Landscape units using Self-Organising Maps

The Hydrogeological Landscape (HGL) framework divides geographic space into regions with similar landscape characteristics. HGL regions or units are used to facilitate appropriate management actions tailored to individual HGL units for specific applications such as dryland salinity and climate-change hazard assessment. HGL units are typically constructed by integrating data including geology, regolith, soils, rainfall, vegetation and landscape morphology, and manually defining boundaries in a GIS environment. In this study, we automatically construct spatially contiguous regions from standard HGL data using Self-Organising Maps (SOM), an unsupervised statistical learning algorithm. We compare the resulting SOM-HGL units with manually interpreted HGL units in terms of their spatial distributions and attribute characteristics. Our results show that multiple SOM-HGL units successfully emulate the spatial distributions of individual HGL units. SOM-HGL units are shown to define subregions of larger HGL units, indicating subtle variations in attribute characteristics and representing landscape complexities not mapped during manual interpretation. We also show that SOM-HGL units with similar attributes can be selected using Boolean logic. Selected SOM-HGL units form regions that closely conform to multiple HGL units not necessarily connected in geographic space. These SOM-HGL units can be used to establish generalised land management strategies for areas with common physical characteristics. The use of SOM for the construction of HGL units reduces the subjectivity with which these units are defined and will be especially useful over large and/or inaccessible regions, where conducting field-based validation is either logistically or economically impractical. The methodology presented here has the potential to contribute significantly to land-management decision-support systems based on the HGL framework. </jats:p

Disrupting Health Professions Education: The Need to Strengthen Educator Skills in Order to Reduce Health Inequities Imposed in Indigenous Peoples

Globally, health inequities persist for Indigenous peoples. Socio-historic-political circumstances, including colonisation, contribute. Health professions courses now mandate Indigenous health curriculum. However, little was known about educator and student interactions with curriculum. This research examined impacts of Indigenous health curriculum on health professional students and the experiences and perspectives of educators. The study revealed problematic centring of non-Indigenous peoples’ and de-centring of Indigenous peoples in curriculum implementation. Current learning and teaching responses provide an insufficient response to health inequity. Development of student and educator skills to mitigate inequity is needed, while decentring non-Indigenous people, and respecting Aboriginal leadership throughout curriculum implementation