Implementation frameworks for polypharmacy management within healthcare organisations: a scoping review.

Several guidelines support polypharmacy management in individual patients. More organisational-level focus is needed on the use of implementation frameworks. The aim of this scoping review was to characterise the peer-reviewed literature on implementation frameworks, focussing on barriers and facilitators to implementation at organisational level in the context of polypharmacy management. A scoping review protocol was devised, supporting retrieval of studies published in English, reporting from any sector of practice. Medline, International Pharmaceutical Abstracts, Cumulative Index of Nursing and Allied Health Literature and Business Source Complete were searched to January 2022 using Medical Subject Headings including: 'polypharmacy', 'deprescriptions', 'strategic planning' and 'organizational innovation'. A narrative approach to data synthesis was applied. Searching, data extraction and synthesis were undertaken independently by two reviewers. After screening 797 records, eight papers remained. Two were descriptive, outlining details of specific initiatives; six used qualitative methods to explore determinants for implementation, including barriers and enablers. Barriers at the organisation level included: poor organisational culture with a lack of sense of urgency and national plans, resource availability and communication issues including patient information and at transitions of care. Organisational facilitators included availability of government funding and regulatory environment promoting patient safety, a national emphasis on quality of care for older adults, co-ordinated national efforts and local evidence. Limited literature focusses on the use of implementation frameworks at organisational levels. This review highlights the need for further work on implementation frameworks in this context to help achieve effective organisational change

A qualitative exploration of key stakeholders’ views and perceptions in relation to organisational change for the implementation of polypharmacy management in Oman.

Polypharmacy contributes to patient non-adherence and increases medication harm. Barriers to implementation prevent desired outcomes when addressing inappropriate polypharmacy at organisational levels and there is a need for theory-based strategies for change management. The objective of this study was to explore the views and perceptions of key stakeholders in relation to organisational change for the development and implementation of a polypharmacy management healthcare strategy in Oman. Qualitative face to face interviews started in March 2022 with key stakeholders in Oman Ministry of Health (MOH) including leaders from practice of Medical, pharmacy and nursing as well as academic leaders from school of medicine, pharmacy and nursing. The interview schedule developed based on a scoping review, Kotter's first three steps of leading change and grounded in the consolidated Framework for Implementation Research (CIFR). Interviews were digitally recorded, transcribed, and analysed independently by at least two researchers using CFIR as a coding framework. Ethics approval was in place prior to data generation. Identified themes related to views and perceptions of key stakeholders in relation to the topic area. To date, ten interviews have been conducted with directors of medical (n=2), pharmacy (2) and nursing practice (1), academic healthcare leaders (3), a healthcare policy developer (1) and patient safety leader (1). Additional interviews are planned and will continue until data saturation. Emerging themes show that participants have views that polypharmacy is a burden on healthcare services and there is a need for organisational change in relation to polypharmacy management. Perceptions of reported organisational level barriers were; fragmentation of care, lack of systems for coordination among healthcare providers, absence of electronic link between the government and private sector, lack of sense of urgency among leaders regarding the polypharmacy and shortage of pharmacists. Facilitators were; the presence of well-developed electronic health system and leadership support. There is a need for for organisational change in relation to polypharmacy management in Oman. Further research is needed to obtain consensus of Omani stakeholders on the plan for a strategic framework for organisational change in relation to polypharmacy management

Using the theoretical domains framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar.

Introduction: A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing. Aim: To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. Methods: This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC. Results: In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all >0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress. Conclusion: A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques

Exploring determinants of antimicrobial prescribing behaviour using the theoretical domains framework.

Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants’ beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship

Persistent fluctuations in stride intervals under fractal auditory stimulation

Copyright @ 2014 Marmelat et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Stride sequences of healthy gait are characterized by persistent long-range correlations, which become anti-persistent in the presence of an isochronous metronome. The latter phenomenon is of particular interest because auditory cueing is generally considered to reduce stride variability and may hence be beneficial for stabilizing gait. Complex systems tend to match their correlation structure when synchronizing. In gait training, can one capitalize on this tendency by using a fractal metronome rather than an isochronous one? We examined whether auditory cues with fractal variations in inter-beat intervals yield similar fractal inter-stride interval variability as isochronous auditory cueing in two complementary experiments. In Experiment 1, participants walked on a treadmill while being paced by either an isochronous or a fractal metronome with different variation strengths between beats in order to test whether participants managed to synchronize with a fractal metronome and to determine the necessary amount of variability for participants to switch from anti-persistent to persistent inter-stride intervals. Participants did synchronize with the metronome despite its fractal randomness. The corresponding coefficient of variation of inter-beat intervals was fixed in Experiment 2, in which participants walked on a treadmill while being paced by non-isochronous metronomes with different scaling exponents. As expected, inter-stride intervals showed persistent correlations similar to self-paced walking only when cueing contained persistent correlations. Our results open up a new window to optimize rhythmic auditory cueing for gait stabilization by integrating fractal fluctuations in the inter-beat intervals.Commission of the European Community and the Netherlands Organisation for Scientific Research

A methylome-wide association study of major depression with out-of-sample case-control classification and trans-ancestry comparison

Major Depression (MD) is a leading cause of global disease burden, and both experimental and population-based studies suggest that differences in DNA methylation (DNAm) may be associated with the condition. However, previous DNAm studies have not so far been widely replicated, suggesting a need for larger meta-analysis studies. In the present study, the Psychiatric Genomics Consortium Major Depressive Disorder working group conducted a meta-analysis of methylome-wide association analysis (MWAS) for life-time MD across 18 studies of 24,754 European-ancestry participants (5,443 MD cases) and an East Asian sample (243 cases, 1846 controls). We identified fifteen CpG sites associated with lifetime MD with methylome-wide significance (p < 6.42e-8). Top CpG effect sizes in European ancestries were positively correlated with those from an independent East Asian MWAS (r = 0.482 and p = 0.068 for significant CpG sites, r = 0.261 and p = 0.009 for the top 100 CpG sites). Methylation score (MS) created using the MWAS summary statistics was significantly associated with MD status in an out-of-sample classification analysis (beta = 0.122, p = 0.005, AUC = 0.53). MS was also associated with five inflammatory markers, with the strongest association found with Tumor Necrosis Factor Beta (beta=-0.154, p=1.5e-5). Mendelian randomisation (MR) analysis demonstrated that 23 CpG sites were potentially causally associated with MD and six of those were replicated in an independent mQTL dataset (Wald's ratio test, absolute β ranged from 0.056 to 0.932, p ranged from 7e-3 to 4.58e-6). CpG sites located in the Major Histocompatibility complex (MHC) region showed the strongest evidence from MR analysis of being associated with MD. Our study provides evidence that variations in DNA methylation are associated with MD, and further evidence supporting involvement of the immune system. Larger sample sizes in diverse ancestries are likely to reveal replicable associations to improve mechanistic inferences with the potential to inform molecular target identification

Patient safety culture in maternity units: a review

YesPurpose: To summarize studies that have examined patient safety culture (PSC) in maternity units and describe the different purposes, study designs and tools reported in these studies, whilst highlighting gaps in the literature. Methodology: Peer-reviewed studies published in English during 1961-2016 across eight electronic databases were subjected to a narrative literature review. Findings: Among 100 articles considered, 28 met the inclusion criteria. The main purposes for studying PSC were: (a) assessing intervention effects on PSC (n= 17); and (b) assessing PSC level (n=7). Patient safety culture was mostly assessed quantitatively using validated questionnaires (n=23). The Safety Attitude Questionnaire was the most commonly used questionnaire (n=17). Intervention varied from a single action lasting five weeks to a more comprehensive package lasting more than four years. The time between the baseline and the follow-up assessment varied from six months up to 24 months. No study reported measurement or intervention costs, and none incorporated the patient’s voice in assessing PSC. Practical Implications: Assessing PSC in maternity units is feasible using validated questionnaires. Interventions to enhance PSC have not been rigorously evaluated. Future studies should report PSC measurement costs, adopt more rigorous evaluation designs, and find ways to incorporate the patient’s voice. Originality/Value: This review summarized studies examining PSC in a highly important area and highlighted main limitations that future studies should consider

Why Current Statistical Approaches to Ransomware Detection Fail

The frequent use of basic statistical techniques to detect ransomware is a popular and intuitive strategy; statistical tests can be used to identify randomness, which in turn can indicate the presence of encryption and, by extension, a ransomware attack. However, common file formats such as images and compressed data can look random from the perspective of some of these tests. In this work, we investigate the current frequent use of statistical tests in the context of ransomware detection, primarily focusing on false positive rates. The main aim of our work is to show that the current over-dependence on simple statistical tests within anti-ransomware tools can cause serious issues with the reliability and consistency of ransomware detection in the form of frequent false classifications. We determined thresholds for five key statistics frequently used in detecting randomness, namely Shannon entropy, chi-square, arithmetic mean, Monte Carlo estimation for Pi and serial correlation coefficient. We obtained a large data set of 84,327 files comprising of images, compressed data and encrypted data. We then tested these thresholds (taken from a variety of previous publications in the literature where possible) against our dataset, showing that the rate of false positives is far beyond what could be considered acceptable. False positive rates were often above 50% and even above 90% on several occasions. False negative rates were also generally between 5% and 20%, numbers which are also far too high. As a direct result of these experiments, we determine that relying on these simple statistical approaches is not good enough to detect ransomware attacks consistently. We instead recommend the exploration of higher-order statistics such as skewness and kurtosis for future ransomware detection techniques

Theoretical approaches in the development and evaluation of behaviour change interversions that improve clinicians' antimicrobial prescribing: a systematic review.

Antimicrobial resistance (AMR) and its threats have long been recognised. Many countries have developed antimicrobial stewardship programmes with strategies to optimise antimicrobial prescribing, minimise AMR and improve outcomes. There remains a need for behaviour change interventions at clinician level to promote appropriate prescribing. Theories should be used for developing and evaluating interventions to change human behaviour. Aim/Objectives: The aim of this review was to critically appraise, synthesise and present the available evidence for theoretical approaches in the development and evaluation of behaviour change interventions designed to improve clinicians' antimicrobial prescribing. Research Design and Methodology: The systematic review protocol was developed and registered with the International Prospective Register of Systematic Reviews (CRD42018098586). MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts, PsycINFO, ScienceDirect, The Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effectiveness, Joanna Briggs Institute Library and Google Scholar were searched for peer-reviewed, English-language studies investigating theoretically based behaviour change interventions designed to improve clinicians’ antimicrobial prescribing in any healthcare setting. Additional studies were obtained from the bibliographies of retrieved papers. Two review authors independently extracted data and assessed study quality. Clinical and methodological heterogeneity limited data synthesis. Results: The searches resulted in 4227 potentially relevant papers after duplicates removal. Screening of titles/abstracts led to retrieval and dual assessment of 38 full-text papers. Of those, a total of 14 studies (4 qualitative, 5 quantitative and 5 mixed-methods) met the inclusion criteria and were included in the systematic review. Most of studies included were from the UK (n = 8) and most were published in 2008 and in 2017 (n = 6); none was published before 2008. The majority of studies were carried out in primary care settings (n = 10) targeting upper respiratory tract infections (n = 7). Theoretical approaches used to inform the design and choice of intervention varied across included studies. The most common included: Theory of Planned Behaviour, Social Cognitive Theory and Operant Learning Theory. Conclusion/Discussion: This systematic review is the first to investigate theoretically based behaviour change interventions for antimicrobial prescribing. Only a small number of primary research studies involving theory in intervention development and evaluation were identified. There is a need for further research in this area. Restricting the review to papers published in English may have been a limitation