A framework for learning about improvement: embedded implementation and evaluation design to optimize learning

Abstract Improving health care involves many actors, often working in complex adaptive systems. Interventions tend to be multi-factorial, implementation activities diverse, and contexts dynamic and complicated. This makes improvement initiatives challenging to describe and evaluate as matching evaluation and program designs can be difficult, requiring collaboration, trust and transparency. Collaboration is required to address important epidemiological principles of bias and confounding. If this does not take place, results may lack credibility because the association between interventions implemented and outcomes achieved is obscure and attribution uncertain. Moreover, lack of clarity about what was implemented, how it was implemented, and the context in which it was implemented often lead to disappointment or outright failure of spread and scale-up efforts. The input of skilled evaluators into the design and conduct of improvement initiatives can be helpful in mitigating these potential problems. While evaluation must be rigorous, if it is too rigid necessary adaptation and learning may be compromised. This article provides a framework and guidance on how improvers and evaluators can work together to design, implement and learn about improvement interventions more effectively

Effectiveness of in-service training plus the collaborative improvement strategy on the quality of routine malaria surveillance data: results of a pilot study in Kayunga District, Uganda.

BACKGROUND: Surveillance data are essential for malaria control, but quality is often poor. The aim of the study was to evaluate the effectiveness of the novel combination of training plus an innovative quality improvement method-collaborative improvement (CI)-on the quality of malaria surveillance data in Uganda. METHODS: The intervention (training plus CI, or TCI), including brief in-service training and CI, was delivered in 5 health facilities (HFs) in Kayunga District from November 2015 to August 2016. HF teams monitored data quality, conducted plan-do-study-act cycles to test changes, attended periodic learning sessions, and received CI coaching. An independent evaluation was conducted to assess data completeness, accuracy, and timeliness. Using an interrupted time series design without a separate control group, data were abstracted from 156,707 outpatient department (OPD) records, laboratory registers, and aggregated monthly reports (MR) for 4 time periods: baseline-12 months, TCI scale-up-5 months; CI implementation-9 months; post-intervention-4 months. Monthly OPD register completeness was measured as the proportion of patient records with a malaria diagnosis with: (1) all data fields completed, and (2) all clinically-relevant fields completed. Accuracy was the relative difference between: (1) number of monthly malaria patients reported in OPD register versus MR, and (2) proportion of positive malaria tests reported in the laboratory register versus MR. Data were analysed with segmented linear regression modelling. RESULTS: Data completeness increased substantially following TCI. Compared to baseline, all-field completeness increased by 60.1%-points (95% confidence interval [CI]: 46.9-73.2%) at mid-point, and clinically-relevant completeness increased by 61.6%-points (95% CI: 56.6-66.7%). A relative - 57.4%-point (95% confidence interval: - 105.5, - 9.3%) change, indicating an improvement in accuracy of malaria test positivity reporting, but no effect on data accuracy for monthly malaria patients, were observed. Cost per additional malaria patient, for whom complete clinically-relevant data were recorded in the OPD register, was $3.53 (95$3.03, $4.15). CONCLUSIONS: TCI improved malaria surveillance completeness considerably, with limited impact on accuracy. Although these results are promising, the intervention's effectiveness should be evaluated in more HFs, with longer follow-up, ideally in a randomized trial, before recommending CI for wide-scale use

Epidemiology of Chlamydia trachomatis in the Middle East and north Africa: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: The epidemiology of Chlamydia trachomatis in the Middle East and north Africa is poorly understood. We aimed to provide a comprehensive epidemiological assessment of C trachomatis infection in the Middle East and north Africa. METHODS: We did a systematic review of C trachomatis infection as well as a meta-analysis and meta-regression of C trachomatis prevalence. We searched PubMed and Embase, as well as regional and national databases up to March 13, 2019, using broad search terms with no language or year restrictions. Any document or report including biological measures for C trachomatis prevalence or incidence was eligible for inclusion. We extracted all measures of current (genital or rectal), recent, and ever infection with C trachomatis. We estimated pooled average prevalence in different populations using random-effects meta-analysis. Factors associated with prevalence and sources of between-study heterogeneity were determined using meta-regression. FINDINGS: We identified a total of 1531 citations, of which 255 reports contributed to 552 C trachomatis prevalence measures from 20 countries. No incidence measures were identified. Pooled prevalence of current genital infection was 3·0% (95% CI 2·3-3·8) in general populations, 2·8% (1·0-5·2) in intermediate-risk populations, 13·2% (7·2-20·7) in female sex workers, 11·3% (9·0-13·7) in infertility clinic attendees, 12·4% (7·9-17·7) in women with miscarriage, 12·4% (9·4-15·7) in symptomatic women, and 17·4% (12·5-22·8) in symptomatic men. Pooled prevalence of current rectal infection was 7·7% (4·2-12·0) in men who have sex with men. Substantial between-study heterogeneity was found. Multivariable meta-regression explained 29·0% of variation. Population type was most strongly associated with prevalence. Additional associations were found with assay type, sample size, country, and sex, but not with sampling methodology or response rate (about 90% of studies used convenience sampling and >75% had unclear response rate). There was no evidence for temporal variation in prevalence between 1982 and 2018. INTERPRETATION: C trachomatis prevalence in the Middle East and north Africa is similar to other regions, but higher than expected given its sexually conservative norms. High prevalence in infertility clinic attendees and in women with miscarriage suggests a potential role for C trachomatis in poor reproductive health outcomes in this region. FUNDING: National Priorities Research Program from the Qatar National Research Fund (a member of Qatar Foundation)

A new fifteen-switch inverter topology for two five-phase motors drive

The multimotor drives supplied from reduced switch-count converter topologies are potentially employed in different applications such as EVs/HEVs and traction systems. Much research work has been done to investigate the feasibility of different series/parallel-motor connections in an appropriate manner while being supplied by a single Voltage Source Inverter (VSI). In this paper, a new Fifteen-Switch Inverter (15-SI) topology for supplying two independent five-phase motors is proposed. This topology can be considered as an extension to the well-known nine-switch converter topology, which can be used to independently control two three-phase motor drives. First, the proposed inverter topology and its mathematical model are presented. Then, three carrier-based Pulse Width Modulation (PWM) schemes to control the converter and their operational constraints are investigated under Common Frequency (CF) and Variable Frequency (VF) modes of operation. The proposed system is validated by simulating the proposed 15-SI feeding two identical five-phase induction motors using Matlab/Simulink.Scopu

How do we learn about improving health care: a call for a new epistemological paradigm

Purpose The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions. Questions We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.) Next steps Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement

Prevalence and use of clinical pathways in 23 countries - an international survey by the European Pathway Association

Objectives To give an overview on the use and prevalence of clinical pathways. Design Cross-sectional descriptive study. Study participants European Pathway Association (E-P-A) contact persons in 23 countries. Results Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care. Conclusions There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation. </jats:sec