Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review

IntroductionNudge-interventions aimed at health professionals are proposed to reduce the overuse and underuse of health services. However, little is known about their effectiveness at changing health professionals’ behaviours in relation to overuse or underuse of tests or treatments.ObjectiveThe aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services.Methods and analysisWe will perform a systematic review. All study designs that include a control comparison will be included. Any qualified health professional, across any specialty or setting, will be included. Only nudge-interventions aimed at altering the behaviour of health professionals will be included. We will examine the effect of choice architecture nudges (default options, active choice, framing effects, order effects) and social nudges (accountable justification and pre-commitment or publicly declared pledge/contract). Studies with outcomes relevant to overuse or underuse of health services will be included. Relevant studies will be identified by a computer-aided search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, CINAHL, Embase and PsycINFO databases. Two independent reviewers will screen studies for eligibility, extract data and perform the risk of bias assessment using the criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We will report our results in a structured synthesis format, as recommended by the Cochrane EPOC group.Ethics and disseminationNo ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Treatment and Prevention of Low Back Pain

The overall aim of this thesis is to investigate treatment and prevention strategies for low back pain. The thesis is divided in two streams. Within the treatment strategies stream, Chapter Two provides an overview of the challenges to manage low back pain in Brazil, a middle-income country where low back pain is the condition with the highest disability burden. Chapter Three investigates the efficacy of antidepressants in people with spinal pain and osteoarthritis. Most antidepressants classes were ineffective for spinal pain. For those that were effective, the magnitude of the difference was small and not clinically important. Antidepressants seemed to be effective for people with sciatica, but the quality of the evidence ranged from low to very low. Chapter Four explores the care profile of people presenting to emergency departments with low back pain in Australia. This study found that, in people presenting to the ED with back pain, about half had a condition beyond the lumbar spine. In those with a lumbar spine condition, 69.6% received an opioid, 23.6% were imaged and 17.6% were admitted. Chapter Five presents the findings of a systematic review that examined the accuracy, comprehensiveness, and credibility of low back pain treatment recommendations from 79 websites. The included websites provided mostly inaccurate information, lack comprehensiveness and had low credibility standards. Within the prevention stream, the thesis focuses on exercise as a strategy for preventing recurrence of low back pain. Chapter Six explored the influence of participant and programme characteristics on people’s willingness to undertake exercise programmes to prevent recurrence of low back pain. Preferences for engaging in exercise programmes were influenced by the characteristics of the programmes themselves. However, there is mismatch between the preferred characteristics of exercise programmes and the characteristics of known effective programmes. In Chapter Eight the effectiveness of exercise and education compared to a minimal intervention in preventing recurrence of low back pain was investigated. Exercise and education were superior to minimal intervention in reducing new episodes of low back pain. A statistical analysis plan of the randomised trial was published a priori and is presented in Chapter Seven

Programa de desenvolvimento dos gestores da Fundação João Pinheiro: inovação, desenvolvimento de pessoas e design thinking

Gestores públicos têm sido cada vez mais demandados por uma atuação inovadora e de liderança no gerenciamento de equipes, promovendo engajamento para o alcance de resultados. Para desenvolver essas competências é importante ir além das exposições teóricas, avançando para a aprendizagem colaborativa e construção de soluções para desafios reais. Este artigo tem como objetivo apresentar a experiência da Fundação João Pinheiro na realização do Programa de Desenvolvimento de Gestores, uma ação de formação desenhada a partir da aprendizagem baseada em problemas. A metodologia utilizada neste trabalho foi um estudo qualitativo a partir de pesquisas bibliográficas e documentais, observação participante e aplicação de questionários.Na etapa de planejamento foi realizada uma pesquisa com os gestores sobre os principais desafios enfrentados. O resultado apontou as competências de liderança e engajamento, gestão de conflitos e comunicação como essenciais para o desenvolvimento gerencial. Após a identificação das competências prioritárias, 38 gestores foram divididos em 6 grupos para trabalhar os temas a partir de uma jornada de design thinking. Os grupos delimitaram os desafios, realizaram uma imersão coletando informações com os usuários, e participaram de exposições teóricas sobre as competências. Algumas propostas apresentadas pelos grupos foram priorizadas para implementação, como a realização de ações de comunicação para o retorno das atividades presenciais e a realização de oficinas de comunicação não violenta, tema que perpassa as três competências trabalhadas.  Os resultados alcançados pelo programa foram além do desenvolvimento de competências, promovendo também a integração dos gestores e a implementação de propostas para desafios da instituição

Testing Bathymetric and Regional Patterns in the Southwest Atlantic Deep Sea Using Infaunal Diversity, Structure, and Function

A better understanding of deep-sea biology requires knowledge of the structure and function of their communities, the spatial, temporal, and environmental patterns, and the changes and dynamics that govern them. Some of the most studied patterns in deep-sea biology are those related to bathymetrical gradients. For meiofauna and nematodes, such studies have highlighted the importance of recognizing regional differences in using ecological mechanisms to explain those patterns. Despite holding significant fisheries and oil and gas resources, the eastern Brazilian Continental Margin is poorly understood with respect to its seafloor biology and ecology. To answer ecological questions of deep-sea infaunal structural and functional diversity in relation to bathymetrical patterns, we used nematode data from five bathymetric transects (400, 1000, 1900, 2500, and 3000 m water depth) sampled in 2011 and 2013 on the Espírito Santo slope off the coast of southeast (SE) Brazil. Deep nematode community analysis based on 6763 nematode identifications showed very high levels of diversity (201 genera; 43 families) compared to other ocean basins and deep-sea regions. Our analyses showed that there is a distinct bathymetric break in standing stocks and community structure between 1000 and 1900 m. Nematode standing stocks were much higher at 400 and 1000 m compared to those for similar depths worldwide, likely linked to the intense and frequent upwelling and specific hydrographic and topographic identity of the region. The bathymetric break was not present for structural and functional nematode diversity. Instead, bathymetric regressions showed that they increased gradually toward 3000 m water depth. The deep Espírito Santo basin is characterized by rich and equitable nematode communities that are both mature and trophically diverse. General deep-sea ecological theories apply to our findings, but there are also substantial regional effects related to the local margin topography, upwelling, and oceanographic and hydrodynamic processes that make the Espírito Santo Basin a unique and diverse deep-sea ecosystem