Implementation Barriers Research Articles

Green Management and Low-Carbon Communities

With the increasing severity of global climate change and environmental issues, green management and the construction of low-carbon communities have become crucial strategies for addressing climate challenges. This paper explores the role of green management in building low-carbon communities, analyzes the challenges faced, and proposes specific construction paths. The study finds that the development of low-carbon communities can be effectively promoted through the formulation and promotion of green management policies, the application of green technologies to enhance community infrastructure, and the encouragement of community participation in low-carbon activities. Despite challenges such as economic and funding issues, technological and implementation barriers, and insufficient community participation, sustainable development of low-carbon communities can be achieved through systematic infrastructure construction, resource management and utilization, lifestyle and community culture promotion, and the application of innovative technologies.

Evaluation of an eating disorder screening and care pathway implementation in a general mental health private inpatient setting

BackgroundGeneral mental health inpatient units hold a valuable place in the stepped system of care, and for identification and treatment of people with eating disorders (EDs) or disordered eating behaviours (DEBs). This study aimed to pragmatically evaluate an evidence-informed screening and care pathway, alongside a staff education program, implemented to improve identification and treatment access for consumers with EDs and DEBs, with co-occurring psychiatric conditions, on a general mental health ward.MethodsA mixed methodology design was mapped to the RE-AIM implementation framework. It encompassed medical record audits across two 3-month time points pre and post implementation of the pathway, and key informant consumer and health professional interviews.ResultsProcess and implementation data were compared for three-month periods pre (2019, n = 348) and post-implementation (2021, n = 284). Post-implementation, intake SCOFF screening occurred in 94.7% of admissions. People with ED/DEBs diagnoses were 35 times more likely to have a SCOFF score ≥ 2 (OR = 35.2, p < .001) with the odds of identifying previously undiagnosed DEBs 3.3 times greater (p = .002). Post-implementation, for those with an ED/DEB, dietitian referrals (p < .001) and micronutrient supplementation (p = .013) were more likely. For those with weight and height data, both absolute (-1.1 kg ± 2.2 vs. 1.3 kg ± 2.3; p < .001) and percentage weight change were significantly higher post-implementation with similarities across BMI categories. Universally, consumers and health professionals expressed that the service had “changed care for the better” encouraging therapeutic relationships, mediated by trust, that resulted in better consumer outcomes. 50 health professionals undertook tailored ED and meal support therapy education. They noted that their knowledge and confidence improved allowing value to be seen in understanding EDs and the role for care within general mental health.ConclusionsThis study demonstrated that an articulated screening and care pathway could be feasibly implemented in general mental health. The evaluation demonstrated advances in ED detection and management with noted improvements in management access, care planning, physical monitoring and weight gain outcomes. Understanding stakeholders’ experiences of new care practices enabled the identification of enablers and barriers for implementation, and avenues to optimise care for consumers with EDs in the general mental health setting.

Barriers and facilitators of screening postpartum depression by primary maternal health workers: A mixed methods study based on the normalization process theory

BackgroundPostpartum depression (PPD) significantly impacts mothers and children's health. China aims to incorporate PPD screening in postpartum home visits, but research on implementation barriers and facilitators is scarce. We designed and implemented a new PPD screening program in Changsha, China, requiring maternal health workers to integrate PPD screening into their postpartum home visits. AimsTo identify real-world barriers and facilitators associated with integrating PPD screening into routine home visits from the perspective of maternal health workers. MethodsWe employed a mixed-methods approach. Maternal health workers involved in the newly introduced PPD screening program were included. Guided by Normalization Process Theory (NPT), quantitative data were collected using the NoMAD instrument, and qualitative data were obtained through semi-structured interviews. Data were analyzed using descriptive statistics for the survey and thematic analysis for the interviews. ResultsAll 42 maternal health workers involved in the new PPD program completed the quantitative survey, and nine participated in qualitative interviews. The NoMAD survey revealed high scores for Coherence and Cognitive Participation, but lower scores for Collective Action, particularly regarding insufficient skills and resource adequacy. Thematic analysis identified several barriers, including workload concerns, the need for enhanced psychological healthcare capacity, and lack of economic incentives. Facilitators included the integration of structured feedback and clear referral pathways. ConclusionAddressing identified barriers through targeted skill training, well-defined referral pathways, and formal recognition of the screening program in performance evaluations could help achieve successful normalization.

Implementation of a telemedical urgency assessment procedure in the pediatric emergency room: evaluation results.

In rural areas in Germany, the number of emergency departments with pediatric expertise decreases. Telemedicine solutions are used sporadically, but they lack certain parameters for assessing a child's health status, such as touch and smell. We tested and evaluated the implementation of a telemedical, cross-hospital urgency assessment in pediatric emergency rooms. The telemedical urgency assessments were carried out via video conferences and were compared to the usual on-site procedure. Primary results of the concordance analysis have been published elsewhere. This work describes the results of the evaluation of the implementation. The telemedical urgency assessment was carried out in 5 pediatric emergency departments during the years 2015-2019. Various methods were used to evaluate the implementation. The following reports are based on (a) a parent questionnaire with two statements to be evaluated (entire project duration), (b) a survey of the physicians using telemedicine after each case (entire project duration) and (c) detailed process documentation (July 2017 until end of the project). A total of 266 patients under 18 years old, recruited from four hospitals, were included in the study. (a) 210 parents completed the questionnaire. 78% of the parents felt adequately cared for and 70% could imagine telemedicine becoming established as a future supplementary care procedure. (b) The physicians' questionnaires for the telemedicine site were completed in 232 cases (87%). The average satisfaction rating was 1.8 on a 6-point-likert-scale (95% confidence interval: 1.64; 1.95). (c) The most frequent implementation problem concerned the technical implementation of the video conference. The evaluation of the accompanying documentation revealed in particular implementation barriers in the technical area (e. g. limited video and/or audio quality) and in the provision of human resources. Despite implementation barriers, the project showed that telemedical urgency assessment in acute pediatric care is a promising option for supporting care. Most of the participating clinicians needed a high level of support, which in some cases indicated a rather low level of digital competence. Increasing acceptance of telemedicine functionalities requires changes in society as a whole with improved framework conditions.

Use of Respiratory Syncytial Virus Vaccines in Adults Aged ≥60 Years: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2024.

Respiratory syncytial virus (RSV) is a major cause of respiratory illness and hospitalization in older adults during fall and winter in the United States. The 2023-2024 RSV season was the first during which RSV vaccination was recommended for U.S. adults aged ≥60 years, using shared clinical decision-making. On June 26, 2024, the Advisory Committee on Immunization Practices voted to update this recommendation as follows: a single dose of any Food and Drug Administration-approved RSV vaccine (Arexvy [GSK]; Abrysvo [Pfizer]; or mResvia [Moderna]) is now recommended for all adults aged ≥75 years and for adults aged 60-74 years who are at increased risk for severe RSV disease. Adults who have previously received RSV vaccine should not receive another dose. This report summarizes the evidence considered for these updated recommendations, including postlicensure data on vaccine effectiveness and safety, and provides clinical guidance for the use of RSV vaccines in adults aged ≥60 years. These updated recommendations are intended to maximize RSV vaccination coverage among persons most likely to benefit, by clarifying who is at highest risk and by reducing implementation barriers associated with the previous shared clinical decision-making recommendation. Continued postlicensure monitoring will guide future recommendations.

A multidisciplinary team and patient perspective on omission of surgery after neoadjuvant systemic therapy for early breast cancer: A European Society of Surgical Oncology (ESSO) Research Academy survey

BackgroundSurgical de-escalation aims to reduce morbidity without compromising oncological outcomes. Trials to de-escalate breast cancer (BC) surgery among exceptional responders after neoadjuvant systemic therapy (NST) are ongoing. Combined patient and clinician insights on this strategy are unknown. MethodsThe European Society of Surgical Oncology Young Surgeons Alumni Club (EYSAC) performed an online survey to evaluate the perspective of multidisciplinary teams (MDTs) on omission of surgery (“no surgery”) following complete response to NST for early BC. The aim was to identify MDT considerations and perceived barriers to omission of BC surgery. Patient insights were obtained through a focused group discussion (FGD) with four members of the patient advocacy group, Guiding Researchers and Advocates to Scientific Partnerships (GRASP). ResultsThe MDT survey had 248 responses, with 229 included for analysis. Criteria for a “no surgery” approach included: patient's tumor and nodal status before (39.7 %) and after (45.9 %) NST and comorbidities (44.3 %). The majority chose standard surgery for hypothetical cases with a complete response to NST. Barriers for implementation were lack of definitive trials (55.9 %), “no surgery” not being discussed in MDTs (28.8 %) and lack of essential diagnostic or therapeutic options (24 %). Patients expressed communication gaps about BC surgery, lack of trust regarding accuracy of imaging, fear of regret and psychosocial burden of choosing less extensive surgery. ConclusionsBefore accepting “no surgery” after complete response to NST, MDTs and patients need level 1 evidence from clinical trials, access to standard diagnostic modalities and treatments. Patient's fear of regretting less surgery need to be acknowledged and addressed.

Nurse-led diuretic titration via a point-of-care urinary sodium sensor in patients with acute decompensated heart failure (EASY-HF): A single-centre, randomized, open-label study.

Early evaluation of the natriuretic response is recommended to guide diuretic therapy in acute decompensated heart failure (ADHF). However, its implementation in daily practice is hampered by implementation barriers and increased time constraints. The Readily Available Urinary Sodium Analysis in Patients with Acute Decompensated Heart Failure (EASY-HF) study assessed the feasibility, efficacy and safety of a nurse-led urinary sodium-based diuretic titration protocol with the use of a point-of-care urinary sodium sensor. The EASY-HF study was a single-centre, randomized, open-label study comparing diuretic management at the treating physician's discretion as standard of care (SOC) with a nurse-led natriuresis-guided protocol in patients with ADHF. The LAQUAtwin Sodium Meter (HORIBA) was used as point-of-care sensor to measure urine sodium concentration. The primary endpoint was natriuresis after 48 h. Secondary endpoints included safety profile and user-friendliness of both the protocol and the point-of-care sensor. Sixty patients were randomized towards SOC (n = 30) versus protocolized care (n = 30). The mean age was 80 ± 8 years, 25% were women and median N-terminal pro-B-type natriuretic peptide was 4667 (2667-7709) ng/L. Natriuresis after 48 h was significantly higher in the protocolized versus SOC group (820 ± 279 vs. 657 ± 273 mmol; p = 0.027). Pre-defined safety endpoints were similar among both groups. The sensor-based protocol was evaluated as easy to use by the nursing staff, and preferred over urinary collections. A nurse-led diuretic titration protocol via a point-of-care urinary sodium sensor was feasible, safe and resulted in an increased natriuresis in ADHF compared to SOC.

Long-acting injectable antiretrovirals for HIV treatment in the ICONA cohort: physicians' and nurses' points of view.

Implementation level of long-acting injectable agents cabotegravir/rilpivirine (LAI CAB/RPV) for human immunodeficiency virus (HIV) treatment in Italy is still not known. The aim of this study is to identify the status of implementation of LAI CAB-RPV and its barriers. A cross-sectional online survey was conducted among infectious diseases (ID) physicians and nurses belonging to the ICONA network in Italy. Three validate 4-items measures were used: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). Out of 61 ICONA centres, 38 (62%) completed the survey: 57.9% were academic centres, 42.1% were hospital-based. In total, 104 respondents were ID physicians (57.4%), 77 were nurses (42.5%); 4.5% of all PWH followed at the 38 centres started LAI CAB/RPV at time of study. Centres taking care of >1000 PWH reported 95% application of procedures for LA implementation, higher than other centres (P = 0.009). Mean score of AIM was (16.0, standard deviation, SD, 3.3), of IAM (16.0, SD 3.0) and FIM (16.0, SD 2.9). A linear correlation was found between AIM and the number of people with HIV who started LAI CAB/RPV (25-50 versus <25, coefficient of correlation [b] 2.57, 95%CI 0.91-4.60, P = 0.004), academic versus hospital-based centres (b -1.59, 95%CI -2.76-0.110044, P = 0.007) and the absence of preliminary systematic assessment of staff (b -1.98, 95%CI -3.31-0.65, P = 0.004). Implementation barriers were not significantly different according to the number of PWH/centre. LAI CAB/RPV implementation was low, with a great variability according to centre size. Tailored and centre-specific interventions to address barriers and to optimize the LA treatment implementation should be designed.

Interdependent Influences of Reverse Logistics Implementation Barriers in the Conditions of an Emerging Economy

This research paper aims to investigate the interdependent influences of barriers to implementing reverse logistics in the broad spectrum of processing activities in the conditions of an emerging economy. An effort was made to approach these barriers (i.e., organizational and management barriers, technical and technological barriers, and economic, financial, and market barriers) based on the relevant literature, predominant attitudes, and experts’ opinions, thus contributing to the body of knowledge in this domain. Determining the intensity of interdependent influences and the importance of barriers for implementing reverse logistics was performed to determine the most important (key) barriers that can be practically applied as guidelines for decision making. The Fuzzy DEMATEL method was used to determine the intensity of these influences on a sample of manufacturing companies in the Republic of Serbia. The results indicate that the most critical barriers to the successful implementation of reverse logistics are a lack of management support and cooperation with scientific institutions and professional associations to acquire knowledge and follow trends in the field.

Simultaneously implementing pathways for improving asthma, pneumonia, and bronchiolitis care for hospitalized children: Protocol for a hybrid effectiveness-implementation, cluster-randomized trial.

Asthma, pneumonia, and bronchiolitis are the top causes of childhood hospitalization in the United States, leading to over 350,000 hospitalizations and ≈$2 billion in costs annually. The majority of these hospitalizations occur in general/community hospitals. Poor guideline adoption by clinicians contributes to poor health outcomes for children hospitalized with these illnesses, including longer recovery time/hospital stay, higher rates of intensive care unit transfer, and increased risk of hospital readmission. A prior single-center study at a children's hospital tested a multicondition clinical pathway intervention (simultaneous implementation of multiple pathways for multiple pediatric conditions) and demonstrated improved clinician guideline adherence and patient health outcomes. This intervention has not yet been studied in community hospitals, which face unique implementation barriers. To study the implementation and effectiveness of a multicondition pathway intervention for children hospitalized with asthma, pneumonia, or bronchiolitis in community hospitals. We will conduct a pragmatic, hybrid effectiveness-implementation, cluster-randomized trial in community hospitals around the United States (1:1 randomization to intervention vs. wait-list control). Our primary outcome will be the adoption of 2-3 evidence-based practices for each condition over a sustained period of 2 years. Secondary outcomes include hospital length of stay, ICU transfer, and readmission. This hybrid trial will lead to a comprehensive understanding of how to pragmatically and sustainably implement a multicondition pathway intervention in community hospitals and an assessment of its effects. Enrollment began in July 2022 and is projected to be completed in September 2024. Primary analysis completion is anticipated in March 2025, with reporting of results following.

Compassion matters in elite sports environments: Insights from high-performance coaches

It is an open question to which degree compassion—noticing, engaging with, and acting to alleviate suffering in self and others—is (considered) advantageous in elite sports. Addressing this question, we herein provide insights into high-performance coaches’ perceptions on the role of compassion in elite sports environments. Specifically, 12 coaches working at the highest level of their respective sport (in Denmark) partook in semi-structured interviews focusing on the utilization, implications, as well as barriers for implementing compassion in elite sports environments. Following a thematic analysis, three themes comprising various subthemes were identified and discussed. The first theme – Benefits of compassion – focuses on coaches’ perception of the use and implications of compassion and comprises four subthemes: Compassion is important when times are tough; Compassion stimulates human connection; Compassion fosters unity in competitive environments; and Compassion promotes performance. The second theme – Increasing compassionate competence – focuses on how a compassionate approach can flourish and comprises three subthemes: Reflection; Awareness and knowledge; and Keeping up with the times. The third theme – Barriers to compassion – focuses on barriers to implementing and enhancing compassion in elite sports environments and comprises four subthemes: Compassion is soft; Power dynamics can stand in the way; Requires prioritization; and Performance outcome orientation. We conclude that while compassion (beyond self-compassion) can be beneficial in elite sports, coaches still perceive barriers for successful implementation, and that research should further investigate the outcomes and consequences of compassion in the elite sport context.

Examining Introduction of E-consent in the Neurosurgical Caseload: Understanding the Barriers to Implementation

ObjectiveTo evaluate current usage and barriers of e-consent implementation in neurosurgical practice. Electronic consent (e-consent) forms provide an alternative method for conducting the informed consent (IC) procedure. IC requires an ability to understand, retain, weigh up and communicate decisions regarding the proposed procedure. Currently, e-consent has shown promise as a method of improving IC, yet barriers to implementation exist. MethodsA comparative analysis regarding procedural and consent data was collected over six months in two neurosurgical centres with elective and emergency caseloads. These were evaluated for changes over time following e-consent introduction. Clinicians were surveyed for their experience using of e-consenting to understand the barriers to implementation. ResultsOver half (55.6%) of neurosurgical procedures made use of e-consent for IC. Lower rates of e-consent were used in trauma related procedures (38.38%) as compared to elective procedures. This did not increase significantly over the study period. Positive clinician survey feedback indicated e-consenting reduces the time required to perform IC, with 50% of respondents strongly agreeing. Barriers to implementation were reported on free-text entry pertaining largely to difficulties in emergency situations due to form complexity. The inability to create and edit templates for personalised e-consent delivery was a further limitation. ConclusionDespite the advantages conferred by e-consent for the administration of IC in neurosurgical procedures, reflected in our survey data, there remains limited use of the technology. Limitations remain relating to ease of access and complexity of use in trauma scenarios.

Identifying the barriers to green infrastructure implementation in semi-arid urban areas using the DPSIR framework: A case study of Amman, Jordan

Research has highlighted the role of green infrastructure (GI) in addressing climate change impacts and other societal and environmental challenges in semi-arid urban areas. Regardless of this potential, GI implementation and research in arid climate zones is limited. Accordingly, using Amman, Jordan as a case study, this research aims to investigate the barriers that impede and prevent GI implementation in semi-arid urban areas. The GI barriers are conceptualized using the Driving–Pressure–State–Impact–Response (DPSIR) framework which was applied on data collected from semi-structured interviews with GI stakeholders in the city. The findings highlighted 17 general implementation barriers grouped into 6 categories. The DPSIR framework specifically highlighted the role of natural and human drivers (e.g. rapid urbanization, institutional capacities, and lacking financial resources) in creating significant barriers to GI implementation. It also illustrated the focus on open spaces and green cover in GI planning in Amman, lacking performance data on GI best practices in semi-arid contexts, and the need of integrated pathways to overcome the identified barriers. The DPSIR framework presents an easy-to-communicate picture of the state of GI implementation in the city that can be utilized by decision-makers, particularly those lacking access to diverse resources. The outcomes of this study enhances our understanding of GI planning in semi-arid urban areas and are beneficial for policymakers and practitioners looking for pathways to promote resilient urban development strategies. Overall, the study calls for further GI research on semi-arid developing contexts.

(Invited) Analytical Validation of Aptamer-Based Blood Drug Measurements Against Clinical Benchmark Methods

The practice of monitoring therapeutic drug concentrations in patient biofluids can significantly improve clinical outcomes while simultaneously minimizing adverse side effects. Although undeniably important to achieve effectiveness, therapeutic drug monitoring remains inconvenient in practice, due primarily to the lengthy process of sample collection, transport to a centralized facility, and analysis using costly instrumentation. Adding to this workflow is the possibility of backlogs at centralized clinical laboratories, which is not uncommon and may result in additional delays between biofluid sampling and concentration measurement, which can negatively affect clinical outcomes. In this talk I explore the possibility of using point-of-care, aptamer-based sensors to minimize the time delay between biofluid sampling and drug measurement. I will discuss analytical validations of aptamer-based blood measurements for two drugs, the antibiotic vancomycin and the antiretroviral drug emtricitabine. We conducted clinical agreement studies comparing the measurement outcomes of electrochemical and optical aptamer-based sensors to the benchmark (1) automated competitive immunoassays for vancomycin monitoring in serum, and (2) liquid chromatography coupled to mass spectrometry detection (LC-MS) for plasma emtricitabine. Our results demonstrate that aptamer-based sensors are selective for the free form of these drugs, and can achieve up to 95% positive correlation and 100% negative correlation with the benchmark assays. Given these results, aptamer sensors offer a promising path for point-of-care drug monitoring that is instantaneous and overcomes current barriers for broad implementation of drug monitoring in clinical settings.

Unlocking AI's potential in the food supply chain: A novel approach to overcoming barriers

This paper delves into the challenges impeding the seamless integration of artificial intelligence (AI) within the food supply chain (FSC) and introduces a novel methodological framework that combines the NK Model with the Decision-Making Trial and Evaluation Laboratory (DEMATEL) technique. Through an exhaustive literature analysis and expert discussions, the research identifies and categorizes significant obstacles to AI deployment in the FSC. These hurdles include the imperative for a skilled labor force, financial limits, regulatory complexity and technological limitations. The unique DEMATEL-NK approach highlights the interconnected nature of these barriers, pinpointing the most critical impediments. The study's implications extend to the broader domains of AI adoption in agriculture and the food industry, offering a nuanced perspective for policymakers, industry stakeholders, and researchers. The findings underscore the imperative of overcoming these barriers for the successful implementation of AI technologies in the FSC, promising advancements in efficiency, quality, and sustainability. The innovative methodology not only sheds light on the interconnectedness of these barriers but also provides a systematic approach for prioritizing and implementing solutions. This research offers a fresh viewpoint on barrier relationships, guiding decision-makers in crafting effective strategies and interventions to propel AI integration in the FSC forward.

Strategies for scaling up pre-ART advanced HIV disease screening at a secondary referral hospital—Malawi: a qualitative study

BackgroundImplementation of the World Health Organization (WHO) recommended Advanced HIV Disease screening package, remains poor in most settings with limited resources. More than 50% of newly diagnosed-HIV clients are missed on screening as a result of implementation barriers. It is important to mitigate the existing barriers and leverage enablers’ inorder to maximize uptake of the advanced HIV disease screening. This study aimed to identify strategies for scaling up implementation of advanced HIV disease screening among newly HIV-diagnosed clients in pre-ART phase using a Consolidated Framework for Implementation Research-Expert Recommendation for Implementing Change (CFIR-ERIC) guiding tool.MethodsA qualitative study was conducted at Rumphi district hospital in Malawi (August – September, 2023). Two sessions of Focus group discussions (FDGs) involving key stakeholders were facilitated to identify specific strategies following the initial study on exploration of barriers and facilitators of advanced HIV disease screening package. Participants comprised healthcare providers, purposively selected from key hospital departments. A deductive approach was used to analyze FDG transcripts where emerging themes were mapped with ERIC list of strategies. CFIR-ERIC Matching tool version 1.0, was used to generate an output of the most to least expert-endorsed Level 1 and Level 2 strategies.FindingsAbout 25 key healthcare workers participated in FDGs. Overall, 6 Level 1 strategies (≥ 50% expert endorsement score) and 4 Level 2 strategies (≥ 20%, ≤ 49% expert endorsement score) were identified, targeting barriers associated with availability of resources, intervention complexity, access to knowledge and information, communication; and implementation leads. Most of the reported strategies were cross-cutting and aimed at enhancing clinical knowledge of the intervention (distributing training materials, educational meetings), developing stakeholders’ interrelations (network weaving) as well as improving clinical workflow (environmental restructuring). Use of evaluative and iterative strategies such as monthly data collection for evaluation were also recommended as part of continuous improvement while an AHD coordinator was recommended to be formally appointed inorder to spearhead coordination of AHD screening services.ConclusionThrough the involvement of key stakeholders and the use of CFIR-ERIC matching tool, this study has identified cross-cutting strategies that if well implemented, can help to mitigate contextual barriers and leverage enablers for an improved delivery of AHD screening package.

A systematic review on the early detection of oral cancer using artificial intelligence and electronic tongue technology

This systematic review examines the role of artificial intelligence (AI) and electronic tongue (e-tongue) technology in the early detection of oral cancer. A comprehensive search of PubMed, Scopus, and Web of Science databases identified 500 articles, of which 20 met the inclusion criteria and were included in the review. The included studies encompassed diverse methodologies, AI models, and e-tongue technologies, with a total of 5,000 participants across various populations. AI-driven models, particularly those utilizing deep learning algorithms, demonstrated high sensitivity (&gt;85%) and specificity (&gt;80%) in detecting oral cancer biomarkers. E-tongue technologies, such as mass spectrometry and optical sensors, contributed to enhanced diagnostic accuracy, with area under the curve (AUC) values exceeding 0.85 in several studies. While promising, challenges such as study heterogeneity, validation in large-scale trials, and implementation barriers require further attention. The findings highlight the transformative potential of AI and e-tongue technology in revolutionizing oral cancer screening and management, with implications for improving patient outcomes and reducing healthcare costs. Future research should focus on standardization, validation, and real-world implementation to harness the full benefits of these innovative approaches in clinical practice.

Factors influencing older adult community fall prevention exercise implementation: a scoping review.

Exercise that challenges balance is the most effective fall prevention intervention in community-dwelling older adults. Identifying factors influencing implementation of community fall prevention exercise programs is a critical step in developing strategies to support program delivery. To identify implementation facilitators, barriers, and details reported in peer-reviewed publications on community fall prevention exercise for older adults. Scoping review. We searched multiple databases up to July 2023 for English-language publications that reported facilitators and/or barriers to implementing an evidence-based fall prevention exercise program in adults aged 50+ years living independently. At least two reviewers independently identified publications and extracted article, implementation, and exercise program characteristics and coded barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR). We included 22 publications between 2001 and July 2023 that reported factors influencing implementation of 10 exercise programs. 293 factors were reported: 183 facilitators, 91 barriers, 6 described as both a facilitator and barrier, and 13 unspecified factors. Factors represented 33 CFIR constructs across all five CFIR domains: implementation inner setting (n = 95 factors); innovation (exercise program) characteristics (n = 84); individuals involved (n = 54); implementation process (n = 40) and outer setting (n = 20). Eight publications reported implementation strategies used; 6 reported using a conceptual framework; and 13 reported implementation outcomes. The high number of factors reflects the complexity of fall prevention exercise implementation. The low reporting of implementation strategies, frameworks and outcomes highlight the ongoing need for work to implement and sustain community fall prevention exercise programs.

A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury

BackgroundVenous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes.This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation.MethodsThe SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a “Living Guideline” process model for the VTE prevention CDS system.DiscussionThe stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.Trial registrationClinicaltrials.gov– NCT05628207. Prospectively registered 11/28/2022, https://classic.clinicaltrials.gov/ct2/show/NCT05628207.

Digital Health: From Remote Monitoring to Remote Care

The growth of digital health technology has led to innovative technological solutions that can help to improve patient care. However, the primary focus to date has been on the passive monitoring of patients, which poses difficulties in clinical integration and has not succeeded in optimizing care for chronic conditions. In this article, we highlight the move from a digital care model focused on the passive monitoring of medical conditions to one where holistic patient management is provided by dedicated external health care teams on a longitudinal basis. This underlines the shift from remote patient monitoring to remote patient care. This approach has thus far mostly been applied at small scales, limited to specific institutions and environments. Generalization to the wider population will likely require the use of centralized entities that can scale these approaches. It is crucial to note that the role of this technology will be to supplement, rather than supplant, in-person care by allowing physicians to focus on the most relevant clinical data collected on a longitudinal basis. This approach is particularly promising for individuals living in rural or underserved areas, where traditional models of care may face barriers in implementation.