Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). Design: A stepped-wedge implementation trial with six geographically diverse sites. Participants: The six facility QI teams were multi-disciplinary, clinical staff. Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. Main measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. Key results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system

Stadtkurier: das Amtsblatt für die Stadt Pockau-Lengefeld mit den Ortsteilen Forchheim, Görsdorf, Lengefeld, Lippersdorf, Nennigmühle, Pockau, Reifland, Wernsdorf und Wünschendorf

Abstract. This multidisciplinary paper reports on a large-scale field trial, designed and implemented by a group of social scientists, computer scientists and statisticians, of a new smartphone-based app for the promotion of walking in everyday life. The app, bActive, is designed for a more diverse range of users than the typical active-lifestyle app, since it requires neither additional equipment nor a great deal of commitment to exercise. As a result, it can raise awareness of walking and promote walking amongst those with only a casual or hesitant engagement with the topic. The 6-week randomised controlled trial with 22-40 year-old male participants (N=152) indicates that bActive prompted users to increase the amount of walking they did by encouraging them to value and increase walking that is incidental to normal everyday activities. Longitudinal data analysis showed that use of the app increased walking by an average of 64 % but did not find any evidence to suggest that the inclusion of comparative social feedback improves the impact of such apps on male participants

Risk of thromboembolic complications after intracerebral hemorrhage according to ethnicity

Introduction: Incidence of thromboembolic (TE) disease varies with race and ethnicity yet little is known about whether these differences also apply to the poststroke period. We review the literature and compare published data with observations from two recent global trials on intracerebral hemorrhage (ICH). Methods: A systematic review of the literature in EMBASE/Medline identified relevant articles. Published data were compared to the TE events-myocardial infarction (MI), cerebral infarction (CI), deep venous thrombosis (DVT), and pulmonary embolism (PE)-observed among placebo patients in two trials investigating the efficacy and safety of recombinant factor VIIa (rFVIIa) (Novo Nordisk A/S, Denmark) in the treatment of spontaneous ICH. The relative risk of TE complications after ICH was estimated for blacks/African Americans and Asians after adjustment for relevant risk factors. Results: Only four relevant studies on TE disease after stroke were identified with data limited to poststroke MI and CI in a mixture of ischemic stroke and ICH patient populations. In the literature, blacks/African Americans appear to have a lower incidence rate of cardiac and cerebro-vascular complications after stroke, and Asians have a higher incidence rate of recurrent strokes, compared with Caucasians. In the two global trials, the overall poststroke incidence rates of MI, CI, DVT, and PE at 3 months after ICH onset were 2.3%, 2.0%, 3.7%, and 1.1%, respectively. After adjustment for differences in baseline risk factors, blacks/African Americans had a significantly higher risk of developing DVT compared with Caucasians (OR=5.64, P=0.0334), while Asians had a strong trend toward a higher risk of DVT (odds ratio=3.22, P=0.0932). The adjusted relative risk of PE, CI, and MI was not significantly different across ethnicities. Conclusion: This is the first study to specifically examine the risk of TE complications in the post-ICH period according to ethnicity. In a limited ICH population, we observed a significantly higher risk of DVT in blacks/African Americans compared with Caucasians after adjustment for differences in risk factors. We observed nonsignificant trends toward differences in the relative risk of MI, CI, or PE across ethnicities