Clinical Behavior Change Research Articles

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives

BackgroundCommunication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results.MethodsThe rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint.ResultsThe rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling better information sharing, implementing adequate planning and utilising technology were also identified in the practice interviews as viable strategies to improve test result communication. The citizen panel highlighted technology as critical to improving communication of test results to both health professionals and patients. Patients also highlighted the importance of having different ways of accessing test results, which is particularly pertinent when ensuring suitability for vulnerable populations.ConclusionsThis paper draws together multiple perspectives on the problem of failures in diagnostic test results communication to inform appropriate interventions. Across the three studies, technology was identified as the most feasible option for closing the loop on test result communication. However, the importance of clear, consistent communication and more streamlined processes were also key elements that emerged.Review registrationThe protocol for the rapid review was registered with PROSPERO CRD42018093316.

A Systematic Review of Trauma Crew Resource Management Training: What Can the United States and the United Kingdom Learn From Each Other?

Crew Resource Management (CRM) training incorporates methods such as simulation, debrief, and teamwork training to emphasize human factors skills. This systematic review aimed to assess differences in CRM between UK and USA trauma personnel. A structured search of the databases MEDLINE and Embase in addition to unstructured reference review and Google Scholar search was undertaken without time restraint to identify articles describing CRM training courses of trauma personnel. Predetermined criteria for inclusion included comprehensive reports of CRM training in trauma personnel with participant assessment. Articles were analyzed for course details and descriptions, Kirkpatrick domains and levels utilized, and measure items and outcomes. Twenty-nine full-text articles (24 USA, 5 UK) met predetermined criteria. UK-based CRM had a heavy emphasis on doctors while USA-based CRM reached a range of multidisciplinary civilian and military professionals. UK-based CRM focused on skills outcomes using pre- and post-training questionnaires, whereas USA-based training focused on behavior and nontechnical skills utilizing validated standardized measures. CRM-based training, and particularly courses incorporating simulation and multidisciplinary methods, resulted in significantly improved preparedness for trauma, emergency skills, and clinical behavioral change. CRM training has the potential to give significant benefits to participant learning, teamwork behaviors, and clinical care outcomes. The USA appears to utilize a focused multidisciplinary and human factors approach to trauma training, which could be adopted by UK institutions to improve cohesive team performance and patient care.

Surgery Resident Perceptions of the Clicker Evaluation System: A Novel Approach to Collecting and Utilizing Clinical Faculty Performance Data

Medical trainees often have a process in place to receive feedback from clinical faculty regarding overall performance. While there is guidance on effective methodologies for faculty to provide feedback for learners, there is a dearth of literature analyzing trainees' evaluation of faculty performance. We sought to identify an effective and anonymous method for surgery residents to evaluate clinical faculty. The Department of Orthopedic Surgery at Virginia Commonwealth University (VCU) Health implemented a novel process to gather annual clinical faculty performance data from residents for the purpose of program improvement starting in 2012. Specifically, residents used a web-based audience response system, also known as a "clicker" system, to evaluate faculty performance over the academic year. During the June 2018 evaluation session, residents also completed an anonymous, 9 question survey to assess the residents' perceptions regarding this clicker evaluation process. VCU Health System, a tertiary care hospital in Richmond, Virginia. All 24 orthopaedic surgery residents at VCU Health participated in the evaluation process and completed the perception survey in 2018. Ninety-six percent (n = 23) of the residents agreed that they are able to accurately rate their attendings' performance, felt confident that their responses remained anonymous, and that their departmental chair values their opinion when evaluating their attendings' performance through the clicker process. Qualitative responses identified anonymity as a strength of the clicker process, while opportunities for improvement included refinement of questions. The clicker evaluation system is an effective and anonymous method for resident evaluation of clinical faculty performance in academic settings. Future steps include refinement of questions based on departmental goals for education, adoption of the clicker evaluation system by other specialties, as well as research into ways to optimize the clicker evaluation process. Additional research should be done to see if and how the clicker evaluation feedback translates into change in clinical faculty behavior.

Mapping of modifiable barriers and facilitators with interdisciplinary chronic obstructive pulmonary disease (COPD) guidelines concordance within hospitals to the Theoretical Domains Framework: a mixed methods systematic review protocol

IntroductionMultifarious chronic obstructive pulmonary disease (COPD) guidelines have been published by local, national and global respiratory societies. These guidelines subsume holistic evidence based on recommendations to diagnose, treat, prevent and...

Potential impact of outpatient stewardship interventions on antibiotic exposures of common bacterial pathogens.

The relationship between antibiotic stewardship and population levels of antibiotic resistance remains unclear. In order to better understand shifts in selective pressure due to stewardship, we use publicly available data to estimate the effect of changes in prescribing on exposures to frequently used antibiotics experienced by potentially pathogenic bacteria that are asymptomatically colonizing the microbiome. We quantify this impact under four hypothetical stewardship strategies. In one scenario, we estimate that elimination of all unnecessary outpatient antibiotic use could avert 6% to 48% (IQR: 17% to 31%) of exposures across pairwise combinations of sixteen common antibiotics and nine bacterial pathogens. All scenarios demonstrate that stewardship interventions, facilitated by changes in clinician behavior and improved diagnostics, have the opportunity to broadly reduce antibiotic exposures across a range of potential pathogens. Concurrent approaches, such as vaccines aiming to reduce infection incidence, are needed to further decrease exposures occurring in 'necessary' contexts.

Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

BackgroundAssessment of clinical variation has attracted increasing interest in health systems internationally due to growing awareness about better value and appropriate health care as a mechanism for enhancing efficient, effective and timely care. Feedback using administrative databases to provide benchmarking data has been utilised in several countries to explore clinical care variation and to enhance guideline adherent care. Whilst methods for detecting variation are well-established, methods for determining variation that is unwarranted and addressing this are strongly debated. This study aimed to synthesize published evidence of the use of feedback approaches to address unwarranted clinical variation (UCV).MethodsA rapid review and narrative evidence synthesis was undertaken as a policy-focused review to understand how feedback approaches have been applied to address UCV specifically. Key words, synonyms and subject headings were used to search the major electronic databases Medline and PubMed between 2000 and 2018. Titles and abstracts of publications were screened by two reviewers and independently checked by a third reviewer. Full text articles were screened against the eligibility criteria. Key findings were extracted and integrated in a narrative synthesis.ResultsFeedback approaches that occurred over a duration of 1 month to 9 years to address clinical variation emerged from 27 publications with quantitative (20), theoretical/conceptual/descriptive work (4) and mixed or multi-method studies (3). Approaches ranged from presenting evidence to individuals, teams and organisations, to providing facilitated tailored feedback supported by a process of ongoing dialogue to enable change. Feedback approaches identified primarily focused on changing clinician decision-making and behaviour. Providing feedback to clinicians was identified, in a range of a settings, as associated with changes in variation such as reducing overuse of tests and treatments, reducing variations in optimal patient clinical outcomes and increasing guideline or protocol adherence.ConclusionsThe review findings suggest value in the use of feedback approaches to respond to clinical variation and understand when action is warranted. Evaluation of the effectiveness of particular feedback approaches is now required to determine if there is an optimal approach to create change where needed.

Simulation-Based Learning to Improve Athletic Trainers’ Knowledge of Exertional Sudden Death Conditions: A Pilot Study

Purpose: Continuing education for the practicing clinician typically involves reading peer-reviewed journals and attending professional conferences. These mechanisms do not allow for practice and real-time evaluation of healthcare skills. Simulation-based learning has been widely used in professional education yet is not common in the continued development of the clinician in their lifespan. Method: We used a cross-sectional, repeated measures pilot study. The participants included 11 athletic trainers (age=40±14 years; certified experience=17±14 years) that engaged in a multi-modal continuing professional development session that included a lecture, large-scale simulated learning experience, and debriefing session at a healthcare conference. The outcome measures included 1) a 6-item effectiveness tool to assess the overall program, 2) pre, post, and 6-month follow-up knowledge assessments, and 3) a 6-month follow-up qualitative viewpoint statement. Results: The participants rated the program as effective and useful. On the knowledge assessment, the participants scored an average of 74% on the pre-test and 87% on the post-test with an average change score of a 20.5% increase following the educational session. We identified a significant improvement (P=0.002) in the participants from pre-test to post-test, however a decay in the knowledge improvements from post-test to follow-up at six months (P=0.188) was noted. Conclusion: A multi-modal educational intervention was effective at improving knowledge immediately following the session. This study offers promise that continuing education through simulation may improve knowledge acquisition while serving as a catalyst for clinical practice behavior change.

Development of an Instrument to Assess the Perceived Effectiveness of Academic Detailing.

Academic detailing (AD) is an effective, evidence-based education outreach method of promoting clinician behavior change. Detailer feedback is important for program evaluation but is rarely systematically collected. The study's objective was to develop a measure capturing the detailer's perception of the effectiveness of an AD program. A six-item measure with a five-level scale was initially developed from the literature review and expert panel consultation. Item constructs were usefulness, acceptability, feasibility, relevance, effectiveness of communication, and readiness to change. The measure was piloted, refined, and tested during an opioid-focused AD program that included two visits. The instrument structure was evaluated using exploratory factor analysis, measure reliability was assessed using item-item correlation (rho), corrected item-total correlation, Cronbach alpha (α), and item response theory. The initial six-item instrument demonstrated unidimensionality. The Cronbach α for the measure was 0.74 (visit 1) and 0.79 (visit 2); one item (relevance) was redundant (α = 0.73 and 0.79 when deleted) and therefore dropped. Items related to usefulness, acceptability, and readiness to change displayed high item-item correlation (rho ≥ 0.50) and contributed the most information and seemed to operate as a single scale (ie, "likelihood to change") based on item response theory analysis. Items related to feasibility and communication were slightly different constructs and should be reported separately. The five-item detailer assessment of visit effectiveness (the "DAVE") instrument provides a standardized approach to assess AD. Further study of its validity and broader use in other programs and educational outreach activities is encouraged.

Medicina defensiva: uma prática em defesa de quem?

Resumo Casos de litígio contra médicos têm aumentado no Brasil: já são três novas ações por hora em decorrência de suposto erro médico. Este estudo objetivou analisar se o médico processado e o profissional que conhece outro colega de profissão que também passou por tal situação alteram a conduta clínica com receio de figurar como réu em ação indenizatória por erro médico. Foi aplicado questionário a 104 médicos de 28 especialidades, 53 mulheres (51%) e 51 homens (49%). Analisou-se a relação entre variáveis como estado civil, tempo médio de formado, vínculos empregatícios, entre outras, e a prática cotidiana da medicina defensiva. O estudo busca promover o debate sobre a alteração da conduta clínica por interesse do médico em não ser processado, desvinculando sua prática e a hipótese diagnóstica do paciente.

Community health workers involvement in preventative care in primary healthcare: a systematic scoping review

ObjectivesTo review effective models of community health worker (CHW) involvement in preventive care for disadvantaged culturally and linguistically diverse (CALD) patients in primary healthcare (PHC) that may be applicable to...

Chromoplexy and Chromothripsis Are Important Prognostically in Myeloma and Deregulate Gene Function By a Range of Mechanisms

Background: Structural variants are key recurrent molecular features of myeloma (MM) with two types of complex rearrangement, chromoplexy and chromothripsis, having been described recently. The contribution of these to MM prognosis, rapid changes in clinical behavior and punctuated evolution is currently unknown as is the mechanism by which they deregulate gene function. Methods: We analyzed two sets of newly diagnosed MM data: 85 cases with phased whole genome sequencing; and 812 cases from CoMMpass where long-insert whole-genome sequencing was available. Patient derived xenografts from five MM cases were used to generate epigenetic maps for the histone marks, BRD4, MED1, H3K27Ac, H3K4me1, H3K4me3, H3K9me3, H3K36me3 and H3K27me3. Results: In the 10X data the median number of structural events per case was 25 (range 1 - 182); with a median of 14 intra-chromosomal events (range 1 - 179; P<0.001) and 7 inter-chromosomal events (range 0 - 29). Structural events were seen most frequently on chromosomes 14 (64%), 8 (53%), 1 (44%) and 6 (42%). Complex chromosomal rearrangements involving 3 or more chromosomal sites were seen in 46%, 4 or more sites in 20%, 5 or more in 10% and 6 or more in 5% of samples. There were significantly more structural events in the t(4;14) subgroup compared to the t(11;14) subgroup. Significantly more events were also seen in the bi-allelically inactivated TP53 cases. Using an elbow test defined cutoff, we identified cases with high structural variant load in 10% of cases. Chromoplexy called by "Chainfinder" was seen in 18% of cases. Chromothripsis called by "Shatterseek" was seen in 9% of cases. Cases with a high structural load alone were not associated with an adverse outcome whereas cases with chromoplexy or chromothripsis were associated with adverse PFS and OS, p=0.001. A new high-risk subgroup comprising approximately 5% of cases was identified with chromoplexy, chromothripsis and a high structural load. Gene set enrichment analysis of cases with chromoplexy and chromothripsis showed an excess of MYC, E2F and G2M targets, and a reduction in RAS signaling. Interferon a and g responses, an excess of TP53 and reduction in TRAF3 mutations was associated predominantly with chromothripsis. How chromoplexy and chromothripsis are tolerated by the cell is unknown and the association with the cGAS/STING response is further being explored. To determine how chromoplexy may deregulate multiple genes we identified the full spectrum of structural variants to the immunoglobulin (Ig) and non-Ig loci. A range of genes are deregulated by Ig loci including MAP3K14 at a frequency of 2% confirming the importance of non-canonical NFkB signaling. A novel intra-chromosomal rearrangement to ZFP36L1 was upregulated in 10% of cases but was not prognostic. Gene upregulation by non-Ig super enhancers is frequent and targets include PAX5, GLI3, CD40, NFKB1, MAP3K14, LRRC37A, LIPG, PHLDA3, ZNF267, CENPF, SLC44A2, MIER1, SOX30, TMEM258, PPIL1, and BUB3. The topologically associating domain (TADs) containing super enhancers bringing about gene deregulation include TXNDC5, FOXO3, FCHSD2, SP2, FAM46C, CACNA1C, TLCD2 and PIK3C2G. These super enhancers frequently contain important MM genes, the coding sequence of which are disrupted by the rearrangement and could contribute to the clinical phenotype. Accurately reconstructing the structure of the complex rearrangements will allow us to identify the mechanism of gene deregulation and to distinguish between either gene stacking, receptor stacking or both. Conclusions: Upregulation of gene expression by super enhancer rearrangement is a major mechanism of gene deregulation in MM and complex structural events contribute significantly to adverse prognosis by a range of mechanisms as well as simple gene overexpression. Disclosures Boyle: Amgen, Abbvie, Janssen, Takeda, Celgene Corporation: Honoraria; Amgen, Janssen, Takeda, Celgene Corporation: Other: Travel expenses. Walker:Celgene: Research Funding. Thakurta:Celgene: Employment, Equity Ownership. Flynt:Celgene Corporation: Employment, Equity Ownership. Davies:Amgen, Celgene, Janssen, Oncopeptides, Roche, Takeda: Membership on an entity's Board of Directors or advisory committees, Other: Consultant/Advisor; Janssen, Celgene: Other: Research Grant, Research Funding. Morgan:Amgen, Roche, Abbvie, Takeda, Celgene, Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Other: research grant, Research Funding.

Implementation of a behavioral medicine approach in physiotherapy: a process evaluation of facilitation methods

BackgroundIn a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences.MethodsAn explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used.ResultsThe physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking.ConclusionsThe findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time.

Defining standard of practice: pros and cons of the usual care arm.

The aim of this review is to describe the use of usual care arms in randomized trials. Randomization of patients to an experimental or a control arm remains paramount for the estimation of average causal effects. Selection of the control arm is as important as the definition of the intervention, and it might include a placebo control, specific standards of care, protocolized usual care, or unrestricted clinical practice. Usual care control arms may enhance generalizability, clinician acceptability of the protocol, patient recruitment, and ensure community equipoise, while at the same time introducing significant variability in the care delivered in the control group. This effect may reduce the difference in treatments delivered between the two groups and lead to a negative result or the requirement for a larger sample size. Moreover, usual care control groups can be subject to changes in clinician behavior induced by the trial itself, or by secular trends in time. Usual care control arms may enhance generalizability while introducing significant limitations. Potential solutions include the use of pretrial surveys to evaluate the extent to which a protocolized control arm reflects the current standard of care and the implementation of adaptive trials.

From Surveys to Skill Sets: Improving Patient Experience by Supporting Clinician Well-Being.

Sharing patient satisfaction survey results is not ideal as a stand-alone motivator for clinician behavior change. Rather, this is best combined with efforts to support clinician well-being by offering protected time to improve our communication skills, along with our ability to effectively process feedback.

Improving Screening and Education for Secondhand Smoke Exposure in Primary Care Settings.

: Exposure to secondhand smoke (SHS), also known as environmental tobacco smoke, adversely affects human health across the life cycle and has important economic consequences. The fact that many health care providers don't routinely screen all patients for SHS exposure and educate them on the risks associated with it is exacerbated by the lack of any requirement to do so, as well as the absence of adequate SHS screening questions in many electronic health record (EHR) systems. Further research on improving screening and education interventions is therefore warranted. In this quality improvement initiative, we introduced flag reminders, visual reminders, education, and a monetary incentive for providers, which improved their screening for and education on SHS exposure in the patients in a primary care clinic. The clinicians' behavior change in response to these interventions supports our proposal that an effective screening question with a flag reminder be added to the EHR, and confirms the need for continued research on screenings, EHR efficacy, and clinical behavior change.

The impact of social norms interventions on clinical behaviour change among health workers: protocol for a systematic review and meta-analysis

BackgroundHealth workers routinely carry out clinical behaviours, such as prescribing, test-ordering or hand-washing, which impact on patient diagnoses, care, treatment and recovery. Social norms are the implicit or explicit rules that a group uses to determine values, beliefs, attitudes and behaviours. A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. This study aims to find out whether or not social norms interventions are effective ways of encouraging health workers to carry out desired behaviours and to identify which types of social norms intervention, if any, are most effective.MethodsA systematic review will be conducted. The inclusion criteria are a population of health professionals, a social norms intervention that seeks to change a clinical behaviour, and randomised controlled trials. Searches will be undertaken in MEDLINE, EMBASE, CINAHL, British Nursing Index, ISI Web of Science, PsycINFO and Cochrane trials. Titles and abstracts will be reviewed against the inclusion criteria to exclude any that are clearly ineligible. Two reviewers will independently screen all the remaining full texts to identify relevant papers. For studies which meet our inclusion criteria, two reviewers will extract data independently, code for behaviour change techniques and assess quality using the Cochrane risk of bias tool. The primary outcome measure will be compliance with desired behaviour. To assess the effect of social norms on the behaviour of health workers, we will perform fixed effects meta-analysis and present forest plots, stratified by behaviour change technique. We will explore sources of variation using meta-regression and may use multi-component-based network meta-analysis to explore which forms of social norms are more likely to be effective, if our data meet the necessary requirements.DiscussionThe study will provide evidence regarding the effectiveness of different methods of applying social norms to change the clinical behaviour of health professionals. We will disseminate the research to academics, health workers and members of the public and use the findings from the review to plan future research on the use of social norms with health workers.Systematic review registrationPROSPERO CRD42016045718. Future protocol changes will be clearly stated in PROSPERO.

Abstract 453: A circulating tumor cell assay for dynamic assessment of drug sensitivity in metastatic castration-resistant prostate cancer

Abstract Background: Tissue-based gene signatures can predict clinical behavior in prostate cancer (PC). Our objective was to extend their application to circulating tumor cells (CTCs) and to show that changes in the signature were associated with changes in clinical behavior. Methods: Our approach combined the Thermoresponsive(TR)-NanoVelcro CTC purification system with the Nanostring nCounter system for cellular purification and transcriptomic analysis. The Prostate Cancer Classification System (PCS) panel was modified for use in CTCs. We selected 31 blood samples from 23 PC patients receiving androgen receptor signaling inhibitors (ARSI) and measured the PCS1 Z score (probability). These findings were compared with clinical outcome data (responsiveness/resistance). Results: A modified, 16-gene PCS1 signature was established and validated through a rigorous bioinformatics process. We performed analytical validation of our combined CTC-RNA system to ensure reproducibility and specificity. In patient bloods, ARSI-resistant samples (ARSI-R, n=14) had significantly higher PCS1 Z scores as compared with ARSI-sensitive samples (ARSI-S, n=17) (Rank-sum test, P=0.003). The analyzed bloods contained samples from 8 patients who developed resistance to an ARSI allowing for dynamic measurement of gene expression. Our analysis found that the PCS1 Z score increased at the time that ARSI-resistance emerged (Pairwise T-test, P=0.016). Conclusions:Using this new methodology, contemporary, clinically-relevant gene signatures such as PCS could be measured non-invasively in CTCs. These findings can be used to relate gene expression to clinical drug response. This approach also allowed for measurement of dynamic variations of gene expression in individual patients over time that correlated to ARSI sensitivity. Citation Format: Pai-Chi Teng, Yu Jen Jan, Junhee Yoon, Jie-Fu Chen, Pin-Jung Chen, Nu Yao, Shirley Cheng, Amber Lozano, Michael R. Freeman, Sungyong You, Hsian-Rong Tseng, Edwin M. Posadas. A circulating tumor cell assay for dynamic assessment of drug sensitivity in metastatic castration-resistant prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 453.

Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation

BackgroundClinical guidelines recommend anticoagulation for patients with atrial fibrillation (AF) at high risk of stroke; however, studies report 40% of this population is not anticoagulated.ObjectiveTo evaluate a population health intervention...

Effectiveness of the spaced education pedagogy for clinicians' continuing professional development: a systematic review.

Ensuring clinical practice reflects current evidence is challenging given the rapid proliferation of new knowledge. Changing entrenched clinical behaviours and facilitating the adoption of best practice evidence requires a range of strategies, including affordable, scalable and effective continuing professional development (CPD). Yet, identifying the CPD delivery method most likely to effectively change and improve patient outcomes is difficult given the variability in the evidence for different learning approaches. Although there is moderate level evidence for outreach education, audit and feedback, and face-to-face or online learning, little is known about the capacity of spaced education to change ineffective clinical practice(s). Spaced education harnesses the power of spacing, repetition and testing learning content to increase topic-specific knowledge. Although spaced education is widely used in undergraduate and postgraduate medical programmes, its effectiveness as a CPD delivery method that improves patient outcomes is less certain. To determine the effectiveness of the spaced education CPD programmes to change targeted clinical knowledge and practice(s) to improve patient outcomes. A systematic review, appraising the spaced education CPD evidence generated from searching six specialist medical and psychosocial databases. Studies published in English peer-reviewed journals from 1 January, 2000 to 31 August, 2018 were eligible for inclusion. A modified Kirkpatrick four levels of evaluation framework assisted with appraising the effect of spaced education CPD interventions on clinicians and patients. Of the 2396 studies identified, 17 met the inclusion criteria, involving 2701 practising clinicians from multiple disciplines and specialties. Five randomised controlled trials generated level II evidence, with the remaining 12 studies generating lower levels of evidence. The majority of studies (n=14) involved the delivery of online spaced education. All studies were evaluated using the modified Kirkpatrick four levels of evaluation framework with: 10 studies demonstrating significant increases in participants' knowledge; seven studies reporting significant changes in clinician behaviour; four studies showing significant increases in clinician confidence; and three studies identifying significant and sustained increases in participants' clinical skills. Only two studies reported positive improvements in patient outcomes. Spaced education via an online platform offers a scalable CPD format that can increase clinical knowledge and change practice. However, further adequately powered randomised controlled trials are required to confirm that spaced education CPD can impact positively on patients' reported outcomes.

Time for reform in transplant program-specific reporting: AST/ASTS transplant metrics taskforce.

In accordance with the National Organ Transplant Act and Department of Health and Human Services' Final Rule, the Scientific Registry of Transplant Recipients (SRTR) publicly releases biannual program-specific reports that include analyses of transplant centers' risk-adjusted waitlist mortality, organ acceptance ratios, transplant rates, and graft and patient survival. Since the inception of these center metrics, 1-year posttransplant graft and patient survival have improved, and center variation has decreased, casting uncertainty on their clinical relevance. The SRTR has recently modified center evaluations by ranking centers into 5 tiers rather than 3 tiers in an attempt to discriminate between programs performing within a tight range, further exacerbating this uncertainty. The American Society of Transplantation/American Society of Transplant Surgeons convened an expert taskforce to examine both the utility and unintended consequences of transplant center metrics. Estimates of center variation in outcomes in adjacent tiers are imprecise and fleeting, but can result in consequential changes in clinician and center behavior. The taskforce has concerns that current metrics, based principally on 1-year graft and patient survival, provide minimal if any benefit in informing patient choice and access to transplantation, with the untoward effect of decreased utilization of organs and restriction of research and innovation.