Effectiveness and efficiency of a practice accreditation program on cardiovascular risk management in primary care: study protocol of a clustered randomized trial

BACKGROUND: Cardiovascular risk management is largely provided in primary healthcare, but not all patients with established cardiovascular diseases receive preventive treatment as recommended. Accreditation of healthcare organizations has been introduced across the world with a range of aims, including the improvement of clinical processes and outcomes. The Dutch College of General Practitioners has launched a program for accreditation of primary care practices, which focuses on chronic illness care. This study aims to determine the effectiveness and efficiency of a practice accreditation program, focusing on patients with established cardiovascular diseases. METHODS/DESIGN: We have planned a two-arm cluster randomized trial with a block design. Seventy primary care practices will be recruited from those who volunteer to participate in the practice accreditation program. Primary care practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician. The intervention group (n = 35 practices) will be instructed to focus improvement on cardiovascular risk management. The control group will be instructed to focus improvement on other domains in the first year of the program. Baseline and follow-up measurements at 12 months after receiving the accreditation certificate are based on a standardized version of the audit in the practice accreditation program. Primary outcomes include controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication. Secondary outcomes are 15 process indicators and two outcome indicators of cardiovascular risk management, self-reported achievement of improvement goals and perceived unintended consequences. The intention to treat analysis is statistically powered to detect a difference of 10% on primary outcomes. The economic evaluation aims to determine the efficiency of the program and investigates the relationship between costs, performance indicators, and accreditation. DISCUSSION: It is important to gain more information about the effectiveness and efficiency of the practice accreditation program to assess if participation is worthwhile regarding the quality of cardiovascular risk management. The results of this study will help to develop the practice accreditation program for primary care practices. TRIAL REGISTRATION: This cluster randomized trial is registered at ClinicalTrials.gov nr NCT0079136

The effect of a multifaceted empowerment strategy on decision making about the number of embryos transferred in in vitro fertilisation: randomised controlled trial

Objective To evaluate the effects of a multifaceted empowerment strategy on the actual use of single embryo transfer after in vitro fertilisation

PENENTUAN DEBIT AIR OPTIMAL DALAM PENDEDERAN BENIH IKAN GABUS Channa striata DI KOLAM TERPAL

Informasi terkait debit air yang sesuai untuk pendederan gabus di kolam terpal saat ini belum tersedia. Tujuan penelitian ini adalah memperoleh debit air yang sesuai terhadap kinerja produksi pada pendederan benih ikan gabus di kolam terpal. Rancangan percobaan yang digunakan adalah rancangan acak lengkap. Perlakuan yang diberikan terdiri atas debit air: 10 mL/detik, 30 mL/detik, 50 mL/detik, dan masing-masing diulang tiga kali. Ikan uji adalah benih ikan gabus dengan bobot rata-rata 0,56 ± 0,070 g/ekor. Ikan uji dipelihara di kolam terpal berukuran 3 m x 3 m x 1 m dengan kedalaman air 20 cm dan padat tebar 50 ekor per m3. Ikan diberi pakan komersial empat kali per hari dengan persentase pemberian 5% biomassa ikan. Lama pemeliharaan ikan uji 40 hari. Parameter uji yang diamati adalah sintasan, pertumbuhan bobot mutlak, pertambahan panjang mutlak, laju pertumbuhan spesifik, efisiensi pakan, kadar glukosa darah, dan kualitas air. Data dianalisis dengan ANOVA dan uji lanjut Duncans. Hasil penelitian menunjukkan debit air 50 mL/detik menghasilkan kinerja produksi terbaik, terlihat dari sintasan (80,67 ± 2,517%); pertumbuhan bobot mutlak (3,69 ± 0,223 g); panjang mutlak (4,32 ± 0,287 cm); laju pertumbuhan spesifik bobot (5,20 ± 0,127% per hari); dan efisiensi pakan terbaik (83,70 ± 3,048%) pada pendederan benih ikan gabus di kolam terpal. Hasil penelitian ini dapat dijadikan dasar untuk pemeliharaan benih ikan gabus pada kolam terpal.The optimum water discharge to culture snakehead fish, Channa striata, juvenile in tarpaulin-covered ponds system is currently unavailable in the literature. This study aimed to determine the optimum water discharge suitable in the nursery stage of snakehead juvenile. The treatments used in the study were as follows: water discharge 10 mL/s, 30 mL/s, and 50 mL/s with three replicates. The snakehead juvenile used had an average body weight of 0.56 ± 0.070 g. The fish were reared in the tarpaulin-covered pond sized 3 m x 3 m x 1 m with a water depth of 20 cm and a stocking density of 50/m3. The fish was fed with a commercial feed four times per day rationed to 5% of body mass for 40 days. The observed parameters consisted of survival rate, absolute weight gain, absolute length, specific growth rate, feed efficiency, blood glucose level, and water quality. Data collected were statistically analyzed using ANOVA followed by Duncan test if there was a significant difference. Results of the study showed that water discharge set at 50 mL/s gave the best production performances in terms of survival rate (80.67 ± 2.517%), absolute weight (3.69 ± 0.223g), and length (4.32 ± 0.287 cm), specific growth rates (5.20 ± 0.127% per day) and feed efficiency (83.70 ± 3.048%). The results of this study can be used as a basis for the rearing of snakehead juvenile in plastic ponds

PENGARUH FREKUENSI PEMBERIAN Moina sp. SEBAGAI PAKAN AWAL PADA PEMELIHARAAN LARVA IKAN GABUS Channa striata DENGAN SISTEM AIR HIJAU

Ikan gabus Channa striata merupakan salah satu komoditas ikan air tawar yang memiliki nilai ekonomis tinggi. Kendala dalam pengembangan budidaya ikan gabus adalah tingginya tingkat kematian pada stadia pemeliharaan larva. Tingginya kematian pada stadia larva karena kecukupan jumlah pakan dan nutrisi pakan awal yang tidak optimum. Tujuan percobaan adalah menentukan frekuensi pemberian Moina sp. yang tepat sebagai pakan awal pada pemeliharaan larva ikan gabus pada sistem air hijau (dengan menambahkan Chlorella sp.). Penelitian dirancang dengan rancangan acak lengkap. Perlakuan yang diberikan adalah frekuensi pemberian Moina sp. per hari sebagai pakan awal: A. enam kali tanpa pemberian Chlorella sp. (kontrol), B. enam kali + Chlorella sp., C. empat kali + Chlorella sp., dan D. dua kali + Chlorella sp. Hasil penelitian menunjukkan pemberian pakan awal dari jenis Moina sp. pada pemeliharan larva ikan gabus pada sistem air hijau dengan frekuensi pemberian dua, empat, dan enam kali dalam sehari memberikan performa sintasan (93,42%-94,29%) dan pertumbuhan tidak berbeda secara nyata (P>0,05). Frekuensi pemberian Moina sp. sebanyak dua kali sehari merupakan perlakuan yang efektif untuk sintasan dan pertumbuhan larva ikan gabus pada pemeliharaan dengan sistem air hijau.Snakehead fish Channa striata is one of the highly-valued freshwater fish commodity. However, its aquaculture development is hampered by a high mortality during larval stage rearing. This high mortality is suspected to be caused by insufficient quantity and quality of food. The purpose of this study was to determine the appropriate feeding frequency using Moina sp. as an initial food for snakehead fish larvae reared in a green water system (Chlorella sp.). A completely randomized design was arranged for this experiment where the treatments consisted of different feeding frequencies of Moina sp. given to the larvae as follows: A) six times a day without the addition of Chlorella sp. (control); B) six times a day with the addition of Chlorella sp.; C) four times a day with the addition of Chlorella sp.; and D) two times a day with the addition of Chlorella sp. The results of the experiment showed that the survival rate (93.42%- 94.29%) and growth of the larvae reared in the green water system with were not significantly different (P>0.05). However, this study suggested that feeding frequency of two times per day was sufficient to support an optimum growth and survival of snakehead larvae reared in a green water system

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people

Contains fulltext : 191679.pdf (publisher's version ) (Open Access

A new combined strategy to implement a community occupational therapy intervention: designing a cluster randomized controlled trial

Contains fulltext : 97575.pdf (publisher's version ) (Open Access)BACKGROUND: Even effective interventions for people with dementia and their caregivers require specific implementation efforts. A pilot study showed that the highly effective community occupational therapy in dementia (COTiD) program was not implemented optimally due to various barriers. To decrease these barriers and make implementation of the program more effective a combined implementation (CI) strategy was developed. In our study we will compare the effectiveness of this CI strategy with the usual educational (ED) strategy. METHODS: In this cluster randomized, single-blinded, controlled trial, each cluster consists of at least two occupational therapists, a manager, and a physician working at Dutch healthcare organizations that deliver community occupational therapy. Forty-five clusters, stratified by healthcare setting (nursing home, hospital, mental health service), have been allocated randomly to either the intervention group (CI strategy) or the control group (ED strategy). The study population consists of the professionals included in each cluster and community-dwelling people with dementia and their caregivers. The primary outcome measures are the use of community OT, the adherence of OTs to the COTiD program, and the cost effectiveness of implementing the COTiD program in outpatient care. Secondary outcome measures are patient and caregiver outcomes and knowledge of managers, physicians and OTs about the COTiD program. DISCUSSION: Implementation research is fairly new in the field of occupational therapy, making this a unique study. This study does not only evaluate the effects of the CI-strategy on professionals, but also the effects of professionals' degree of implementation on client and caregiver outcomes. CLINICAL TRIALS REGISTRATION: NCT01117285

Technical efficiency evaluation of colorectal cancer care for older patients in Dutch hospitals

BACKGROUND: Preoperative colorectal cancer care pathways for older patients show considerable practice variation between Dutch hospitals due to differences in interpretation and implementation of guideline-based recommendations. This study aims to report this practice variation in preoperative care between Dutch hospitals in terms of technical efficiency and identifying associated factors. METHODS: Data on preoperative involvement of geriatricians, physical therapists and dieticians and the clinicians’ judgement on prehabilitation implementation were collected using quality indicators and questionnaires among colorectal cancer surgeons and specialized nurses. These data were combined with registry-based data on postoperative outcomes obtained from the Dutch Surgical Colorectal Audit for patients aged ≥75 years. A two-stage data envelopment analysis (DEA) approach was used to calculate bias-corrected DEA technical efficiency scores, reflecting the extent to which a hospital invests in multidisciplinary preoperative care (input) in relation to postoperative outcomes (output). In the second stage, hospital care characteristics were used in a bootstrap truncated regression to explain variations in measured efficiency scores. RESULTS: Data of 25 Dutch hospitals were analyzed. There was relevant practice variation in bias-corrected technical efficiency scores (ranging from 0.416 to 0.968) regarding preoperative colorectal cancer surgery. The average efficiency score of hospitals was significantly different from the efficient frontier (p = <0.001). After case-mix correction, higher technical efficiency was associated with larger practice size (p = <0.001), surgery performed in a general hospital versus a university hospital (p = <0.001) and implementation of prehabilitation (p = <0.001). CONCLUSION: This study showed considerable variation in technical efficiency of preoperative colorectal cancer care for older patients as provided by Dutch hospitals. In addition to higher technical efficiency in high-volume hospitals and general hospitals, offering a care pathway that includes prehabilitation was positively related to technical efficiency of hospitals offering colorectal cancer care

Time to incorporate time in cost-effectiveness analysis

Cost-effectiveness analysis as a means to evaluate medical innovations has become well accepted in the UK and several other Western countries. An important assumption underlying this method is that costs and effects are constant over time. In reality, however, and especially in the short run, variations in costs and effects are likely to occur. These variations can lead to considerable deviations from the outcome of a conventional economic evaluation, which in turn may lead to serious implementation problems at a local level. Taking time into account explicitly in economic evaluations in health care may enhance their utility for both societal and local decision making, and may ultimately smooth the adoption of new and basically cost-effective health care technologies

Improving person-centred care in nursing homes through dementia-care mapping: design of a cluster-randomised controlled trial

Contains fulltext : 108278.pdf (postprint version ) (Open Access)BACKGROUND: The effectiveness and efficiency of nursing-home dementia care are suboptimal: there are high rates of neuropsychiatric symptoms among the residents and work-related stress among the staff. Dementia-care mapping is a person-centred care method that may alleviate both the resident and the staff problems. The main objective of this study is to evaluate the effectiveness and cost-effectiveness of dementia-care mapping in nursing-home dementia care. METHODS/DESIGN: The study is a cluster-randomised controlled trial, with nursing homes grouped in clusters. Studywise minimisation is the allocation method. Nursing homes in the intervention group will receive a dementia-care-mapping intervention, while the control group will receive usual care. The primary outcome measure is resident agitation, to be assessed with the Cohen-Mansfield Agitation Inventory. The secondary outcomes are resident neuropsychiatric symptoms, assessed with the Neuropsychiatric Inventory - Nursing Homes and quality of life, assessed with Qualidem and the EQ-5D. The staff outcomes are stress reactions, job satisfaction and job-stress-related absenteeism, and staff turnover rate, assessed with the Questionnaire about Experience and Assessment of Work, the General Health Questionnaire-12, and the Maastricht Job Satisfaction Scale for Health Care, respectively. We will collect the data from the questionnaires and electronic registration systems. We will employ linear mixed-effect models and cost-effectiveness analyses to evaluate the outcomes. We will use structural equation modelling in the secondary analysis to evaluate the plausibility of a theoretical model regarding the effectiveness of the dementia-care mapping intervention. We will set up process analyses, including focus groups with staff, to determine the relevant facilitators of and barriers to implementing dementia-care mapping broadly. DISCUSSION: A novelty of dementia-care mapping is that it offers an integral person-centred approach to dementia care in nursing homes. The major strengths of the study design are the large sample size, the cluster-randomisation, and the one-year follow-up. The generalisability of the implementation strategies may be questionable because the motivation for person-centred care in both the intervention and control nursing homes is above average. The results of this study may be useful in improving the quality of care and are relevant for policymakers. TRIAL REGISTRATION: The trial is registered in the Netherlands National Trial Register: NTR2314

Effects of Dementia-Care Mapping on Residents and Staff of Care Homes:A Pragmatic Cluster-Randomised Controlled Trial

BACKGROUND: The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention. METHODS: Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents’ neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects. RESULTS: 34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI −2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects. CONCLUSIONS: Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect. TRIAL REGISTRATION: Dutch Trials Registry NTR2314