Evidence-practice Gap Research Articles

Action, actor, context, target, time (AACTT): a framework for specifying behaviour

BackgroundDesigning implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention’s effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system.Methods and resultsWe used French et al.’s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions.ConclusionsDescribing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions.

Evidence summary resources may influence clinical decision making: A case-based scenario evaluation of an evidence summary tool

PurposeEvidence summary resources are popular with clinicians but it is unknown whether they can influence clinical decision making. We evaluated whether an extremely condensed and explicit evidence summary tool could influence clinical decision making. Materials and methodsAn evidence summary tool was developed using a formal mapping exercise and graphic design principles. An invitation to participate was sent to subscribers of a critical care e-mail discussion list. Participants received a study package (evidence summary tool précising prone positioning in severe ARDS; case-based scenario describing a patient with severe ARDS plus evaluation questionnaire). Influence on clinical decisions was captured regarding six competing interventions, with Belief in benefit measured before and after reading the summary tool. ResultsAmong 93 participants, 87% were male with a mean age of 49.6(SD9.3) years. Mean ICU experience was 20.0(SD9.9) years.The evidence summary tool significantly influenced clinical decision making: belief in benefit of prone positioning increased (P < .001), belief in benefit of higher PEEP decreased (P = .002) and belief in benefit in ECMO decreased (P = .07). ConclusionsUsing a before-after evaluation, we demonstrated an extremely condensed and explicit information format can influence clinical decision making. Evidence summary tools may be a useful adjunct to support closing evidence-practice gaps.

THE HEART OUTCOMES PREVENTION EVALUATION 4 CANADA: A PILOT STUDY OF A COMMUNITY-BASED, MULTI-FACETED INTERVENTION, LED BY NON-PHYSICIANS TO REDUCE CARDIOVASCULAR RISK IN PEOPLE WITH HYPERTENSION

Significant evidence-practice gaps in the treatment of cardiovascular (CV) risk have been demonstrated. The objective of HOPE4 was to pilot a community-based, multi-faceted intervention to screen, diagnose and improve long-term CV risk in people with hypertension. Building upon existing local infrastructures, firefighters in Surrey, BC and community health-workers in Hamilton, ON involved in community outreach programs, were trained as part of the HOPE4 intervention.

P6531Evidence-practice gap in the preprocedural risk assessment for contrast-induced acute kidney injury

Abstract Background Contrast-induced acute kidney injury (CI-AKI) is one of the frequently encountered and costly complications after percutaneous coronary intervention (PCI). Clinical practice guidelines strongly recommend that PCI patients should universally undergo preprocedural assessment for the risk of CI-AKI, and the contrast volume (CV) should be minimized to an achievable level, particularly among the high AKI risk patients. However, data on the CV use based on the comprehensive preprocedural risk assessment is still lacking. Purpose Our study aimed to 1) assess the impact of CV increase with the incidence of AKI among high AKI risk patients, and 2) retrospectively evaluate the used CV based on the preprocedural comprehensive risk assessment for patients undergoing PCI within multicenter longitudinal registry. Methods Between 2009 and 2018, 22,373 patients underwent PCI in 14 participating facilities, and consecutive patient data was registered. AKI was defined as a &gt;0.3mg/dl absolute or &gt;1.5-fold relative increase in post-PCI creatinine or new initiation of dialysis, based on the Acute Kidney Injury Network criteria. The post-procedural creatinine was defined as the highest value within 30 days after the indexed procedure. Congruent with the National Cardiovascular Data Registry (NCDR) definition, if more than 1 post-procedural creatinine level was measured, the highest value was used for determining AKI. We divided the patients into four groups according to quartile of NCDR AKI risk scores. Results Mean age of the patients were 68.7±11.1 years, and 79.1% were male. Mean CV use was 161.4±74.8ml. The incidence of CI-AKI was 8.9%, and was particularly high among high AKI risk patients (21.1%); CV (per 1ml linear increase) was directly associated with the occurrence of AKI (OR: 1.002 per unit in CV; 95% CI: 1.001–1.003; P&lt;0.001) in these patients. CV during PCI decreased with the progression of chronic kidney disease (CKD), but it did not alter by the overall NCDR AKI risk score (Figure). After multivariable adjustment, CV was predicted by stage of CKD (−13.68ml; 95% CI: −12.05 to −15.30ml; P&lt;0.001), but not by the value of pre-procedure prediction score (NCDR AKI risk score, P=0.575). CV according to CKD/NCDR AKI risk score Conclusions Higher CV was directly associated with the occurrence of AKI among higher AKI risk patients. However, CV use was largely influenced by the stage of renal disease, and not with overall patient risk presented by contemporary risk scores. Our results have identified an important evidence-practice gap and emphasizes the importance of total preprocedural assessment to minimize CV and prevent subsequent AKI. Acknowledgement/Funding KAKENHI (16KK0186, 16H05215, 25460630, 25460777), Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Teikoku Seiyaku, Sumitomo Dainippon, AstraZeneka, Pfizer

P5319Evidence-practice gaps in the screening and management of cardiovascular risk factors in the Australian General Practice population

Abstract Background Cardiovascular disease (CVD) is a major cause of death and disability in Australia affecting 1 in 6 of the Australian population. Studies a decade ago showed large evidence-practice gaps in the screening and management of CVD risk in Australian General Practice. A new risk-based screening and management guideline was launched in 2012. Purpose This study aimed to update the evidence to evaluate appropriate screening for, and management of, cardiovascular risk factors in Australian General Practice and explore practice and patient level predictors for appropriate screening and management. Methods Cross-sectional de-identified data from GP electronic health records were extracted for patients &gt;18 years having attended at least once in the last 6 months and 3 times in the last 2 years (i.e. active patients). Practice-level data were also collected manually. The statistical cohort included Aboriginal and Torres Strait Islander people 35+ years and all others 45+ years, or any individual classified as “high CVD risk” regardless of age. High risk was defined as having either established CVD, pre-defined clinically high risk conditions or a calculated 5-year risk &gt;15% using a Framingham based risk calculator. Appropriate screening was defined as having recorded/updated all essential risk factors for measurement of CVD risk within recommended time frames. Appropriate management was defined as: ≥1 BP lowering drug and a statin for people at high risk without CVD and the addition of an antiplatelet or anticoagulant agent for people with established CVD. Results Data were available on 110686 patients from 98 General Practices of which 55% were female, 1.4% of Aboriginal or Torres Strait Islander background, 14% current or ex-smoker and 15% with Diabetes. Forty-nine percent had complete and up to date screening information. Twenty-six percent were classified as high risk of which 11% had established CVD. Fifty-one per cent of those with established CVD were on appropriate treatment, vs 38% of those at high risk but without CVD. A greater proportion of males received appropriate screening (51.5% vs 47.5%). Females were less likely to receive recommended therapy (44.2% vs 55.1%) for secondary prevention but more likely for primary prevention (42% vs 35.5%). For those on BP lowering therapy, only 37% of those with CVD were reaching their target BP compared to 54% of those at high risk without established disease. 56% of those with CVD on lipid lowering therapy were reaching their targets compared to 45% of those at high risk without CVD. Conclusion Despite availability of a national guideline, gaps remain large for the management of CVD in Australian General Practice. Female primary prevention patients appear to receive better screening and treatment than their male counterparts, but this is reversed when they have established disease. Analysis of patient and practice level predictors for these gaps is currently underway. Acknowledgement/Funding National Health and Medical Research Council

Physician Adherence to Treat-to-Target and Practice Guidelines in Rheumatoid Arthritis.

Principles of treat-to-target (T2T) have been widely adopted in both multinational and regional guidelines for rheumatoid arthritis (RA). Several questionnaire studies among physicians and real-world data have suggested that an evidence–practice gap exists in RA management. Investigating physician adherence to T2T, which requires a process measure, is difficult. Different practice patterns among physicians are observed, while adherence to protocolized treatment declines over time. Rheumatologist awareness, agreement, and claims of adherence to T2T guidelines are not always consistent with medical records. Comorbidities, a difficult disease course, communication barriers, and individual preferences may hinder an intensive, proactive treatment stance. Interpreting deviations from protocolized treatment/T2T guidelines requires sufficient clinical context, though higher adherence seems to improve clinical outcomes. Nonmedical constraints in routine care may consist of barriers in healthcare structure and socioeconomic factors. Therefore, strategies to improve the institution of T2T should be tailored to local healthcare. Educational interventions to improve T2T adherence among physicians may show a moderate, although beneficial effect. Meanwhile, a proportion of patients with inadequately controlled RA exists, while management decisions may not be in accordance with T2T. Physicians tend to be aware of current guidelines, but their institution in routine practice seems challenging, which warrants attention and further study.

Evaluation of a community of practice for speech-language pathologists in aphasia rehabilitation: a logic analysis

BackgroundAphasia is a communication disorder affecting participation. Although there are evidence-based practice recommendations about participation and aphasia rehabilitation, it may be challenging for speech-language pathologists to ensure that rehabilitation activities have an impact on the person’s participation, in part due to time limitations. Participation remains limited after rehabilitation for persons who have aphasia. Communities of practice (CoPs) are a collaborative knowledge transfer strategy that can be used for evidence-based practice implementation. The aim of this study was to describe the components and evaluate a CoP for speech-language pathologists about participation and aphasia rehabilitation.MethodsLogic analysis was used to determine the adequacy between resources, implemented activities, outputs and short-term outcomes of the CoP. Qualitative and quantitative descriptive data were collected through observation and participants’ logbooks. Outputs and outcomes of the CoP were revealed through thematic analysis and interpretation of descriptive statistics.ResultsResources including CoP design and educational aims, human and material resources were combined to create various web-based, online and offline activities. Participants invested more time per week than expected in the CoP, shared and created clinical tools and appreciated the array of suggested activities. Participant engagement allowed them to reflect, interact and collaborate with each other. All 13 participants reported they acquired knowledge about clinical tools and 12 mentioned they reflected on their practice. While the CoP was ongoing, six participants noticed evidence-practice gaps, seven prepared to change their practice, and three changed their practice towards including more participation-based considerations.ConclusionsThis study showed that speech-language pathologists can include more participation-based approaches in aphasia rehabilitation as a result of participating in a time-bound, web-based CoP.

Status of use of protease inhibitors for the prevention and treatment of pancreatitis after endoscopic retrograde cholangiopancreatography: An epidemiologic analysis of the evidence-practice gap using a health insurance claims database.

Existing evidence suggests that protease inhibitors (PIs) used to prevent or treat pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) are ineffective, and their use is not recommended by clinical practice guidelines. However, in Japan, PIs are administered with the aim to prevent or treat post-ERCP pancreatitis. This study aimed to clarify the gap between guideline recommendations and contents of practice. We used the health insurance claims database of Japan Medical Data Center. Among patients who had undergone ERCP, those with acute pancreatitis or post-ERCP pancreatitis recorded in claims as disease names were defined as post-ERCP pancreatitis patients. The study period was divided into three terms according to the date of publication of clinical practice guidelines for acute pancreatitis. Among 2,945 patients who had undergone ERCP, 2,847 were eligible for analysis. Of these, 1,375 (48.3%) patients had claims with pancreatitis recorded as the disease name; PIs were prescribed to 1,238 (90.0%). Rates of prescription of PIs were 72.3% in 2005-07, 70.9% in 2008-09, and 83.6% in 2010-15, showing a significant increase (p < 0.001). In conclusion, PIs are administered in clinical practice in Japan for the purpose of preventing or treating pancreatitis, with an increasing trend in prescription in recent years.

An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey

BackgroundPatients with pain associated with musculoskeletal disorders often seek treatment from physiotherapists, necessitating these practitioners’ competence to practice within the biopsychosocial framework. Qualitative research suggests musculoskeletal physiotherapists may not have adequate proficiency in psychosocial practice to assess and address psychosocial factors effectively. ObjectiveTo collect quantitative self-report data via an online survey from a large cross section of Australian musculoskeletal physiotherapists regarding their psychosocial practice. MethodsThe study involved an iterative survey development process followed by the conduct of this survey. A provisional survey named the ‘Triple P Questionnaire’ was developed, informed by the knowledge and experience of the research team. This Questionnaire was piloted by experts (n = 6) to provide feedback on the instrument. Changes were made to the survey based on this feedback. The finalised Triple P Questionnaire was distributed to Australian musculoskeletal physiotherapists. Results181 participants completed the full survey. Not all demographic characteristics were representative of the population. Most participants indicated that they ‘agree’ to most statements posed in the questionnaire including confidence, routine practice of specific psychosocial skills and barriers. Some questions presented a majority response of ‘disagree’ or a spread of responses, indicating some evidence-practice gaps, including the use of questionnaires, and explicit assessment of psychological factors. Inferential statistics revealed no significant correlations between demographic characteristics and psychosocial practice. ConclusionThe Triple P Questionnaire identified musculoskeletal physiotherapists’ generalconfidence in their psychosocial practice but highlights some apparent inconsistencies in reported practice and areas where confidence is not as strong, reflecting possible evidence practice gaps.

Local opinion leaders: effects on professional practice and healthcare outcomes.

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011. To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes. We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field. We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs. We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention. We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs. Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Persistent SIRS and non-alcohol etiology of AP are associated with oral feeding intolerance in AP: Results from an international, multicenter, prospective cohort study

Venous leg ulcers represent the most common chronic wound problem managed in Australian primary care. Despite the prevalence of the condition, there is an evidence-practice gap in both diagnosis and management of venous leg ulcers.We used the Theoretical Domains Framework to identify barriers and enablers perceived by primary care practitioners in implementing venous leg ulcer guidelines in clinical practice.We collected data to explore the experiences of practice nurses and general practitioners related to their use of clinical practice guidelines in management of venous leg ulcers.We recruited participants from primary care settings located in metropolitan and rural areas across Victoria, Australia.We recruited general practitioners (15) and practice nurses (20).We conducted 35 semi-structured face-to-face and telephone interviews. Content analysis of health practitioners’ statements was performed and barriers to implementing clinical practice guidelines were mapped across the Theoretical Domains Framework theoretical domains.Six main domains from the Theoretical Domains Framework (Environmental context and resources, Knowledge, Skills, Social influences, Social/Professional Role and Identity and Belief about Capabilities) best explained these barriers and enablers. Many participants were not aware of venous leg ulcer clinical practice guidelines. Those that were aware, stated that finding and accessing guidelines was challenging and most participants relied on other sources of information. Venous leg ulcer management was greatly influenced by professional experience and suggestions from colleagues. Other barriers included busy clinical practice, absence of handheld Doppler ultrasonography, insufficient skills and a lack of confidence related to the use of technology to rule out arterial involvement prior to compression application, a particular skill related to venous leg ulcer management that will impact on healing outcomes.We identified a number of barriers and the lack of enablers that influence the uptake of venous leg ulcer clinical practice guidelines in primary care. This paper adds a theoretically sound, systematic approach for understanding and addressing the behaviour change required to improve translation of venous leg ulcer clinical practice guidelines in clinical practice.Tweetable abstract: The need to optimise venous leg ulcer clinical practice guidelines (CPG) has never been greater as the current estimate of health cost is AUD3billion and increasing due to rising epidemics of diabetes and obesity. We found most primary care health practitioners are unaware of CPG and this will impact on health and healing outcomes in Australian primary care.

Does hospital information technology infrastructure promote the implementation of clinical practice guidelines? A multicentre observational study of Japanese hospitals

ObjectivesIt remains unclear whether insufficient information technology (IT) infrastructure in hospitals hinders implementation of clinical practice guidelines (CPGs) and affects healthcare quality. The objectives of this study were to describe...

Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines

BackgroundHigh-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.MethodsSub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.ResultsAfter excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P < 0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P < 0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)].ConclusionsFacility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

LO23: Identifying patient values and expectations for pulmonary embolism CT scanning in the emergency department

Introduction: There is an evidence-practice gap between guidelines for diagnosing pulmonary embolism (PE) and emergency physician practice. Computed tomography (CT) scanning is being overused to exclude PE in Canadian emergency departments (EDs) and current guidelines do not fit well with the ED model of patient care. There is a lack of research on patient opinions on PE testing, and a poor physician understanding of patient-specific goals in the ED. We are addressing this by conducting patient interviews to identify patient-specific values and opinions on PE testing in the ED. These will be used to develop patient-centered educational tools which physicians and patients can use to discuss the decision to order a CT PE scan. The aim of this study is to identify patient expectations and priorities on PE testing in the ED. Methods: This qualitative study uses constructivist grounded theory to analyze patient values and opinions on PE testing in ED patients from two hospitals. Participants are screened by monitoring the ED patient tracker. If a patient is being tested for PE, they are approached and consented by a researcher to take part in a 30-minute semi-structured interview. Each interview is transcribed verbatim and independently analyzed by four researchers using constant comparative coding. The researchers meet weekly to compare codes and agree on common coding terms. The codes are grouped into themes, and the interview script is modified to maximize information on emerging themes. From this, major themes with associated subthemes will be derived, each representing an opportunity, barrier or value which must be addressed in our new patient education tools. We have performed 23 interviews and expect to reach theme saturation at 30 interviews. Full results will be available by the 2019 CAEP conference. Results: From the patient interviews conducted so far, we have mapped four major themes: patient satisfaction comes from addressing their primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination when testing for PE; and patients expect 100% confidence from their ED physician when given a diagnosis. Conclusion: These four domains will be used to create a new patient-centered approach to PE testing in the ED which will include physician education, patient information and organizational changes to patient processing. This study incorporates evidence-based medicine with ethical and social implications to improve patient outcomes.

Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction.

New research findings may not lead to change in practice, or a change at the front line may be delayed by years. A number of terms have been used to describe efforts and strategies to speed a change in evidence-based practice, such as: implementation science, knowledge translation, research translation and others. In contrast to traditional clinical research, implementation science generally aims to understand and change health professional behaviour to promote evidence uptake as opposed to attempting to change patient behaviour. There are now theoretical frameworks and evolving evidence providing guidance how to change clinician behaviour and, specifically, emerging evidence on how to achieve this in the emergency setting. This review will provide an introduction to implementation science and illustrate how to target evidence practice gaps using ED examples.

Development of a participatory, tailored behaviour change intervention to increase active practice during inpatient stroke rehabilitation

Purpose: An evidence-practice gap exists between the amount of active practice recommended and the amount completed by stroke inpatients. The aim of this paper is to describe steps in the design of a participatory, theoretically tailored staff behaviour change intervention to help staff use strategies to increase active practice by stroke inpatients.Methods: A staff behaviour change intervention was developed in one rehabilitation unit in Queensland, Australia using a six-step process guided by the Behaviour Change Wheel framework. Mixed methods were used including direct observation (behavioural mapping), and focus groups to identify barriers and facilitators to implementation. Barriers and facilitators were mapped to the behaviour change techniques, and a behaviour change intervention developed in participation with rehabilitation staff.Results: Staff chose to implement ward-based practice books. Barriers included patient factors (including low motivation and severity of stroke), environmental segregation and limited skills for motivating patients. Staff belief in increasing active practice was a facilitator to implementation. The staff intervention included a training programme about motivation, environmental restructuring, audit, and feedback.Conclusions: This example of collaborative implementation research can be used and adapted by clinicians and researchers in other rehabilitation services.IMPLICATIONS FOR REHABILITATIONRehabilitation staff can be actively involved in designing behaviour change interventions.Behaviour change interventions should target local barriers to increase activity levels and practice completed by stroke inpatients.The process of co-designing behaviour change interventions has the potential to improve the uptake of a strategy such as ward-based practice books, by more precisely identifying local barriers and possible solutions.

Multi-level reform is required to support high-value osteoarthritis care delivery: outcomes of a multinational survey of clinicians and students

Purpose: Evidence-practice gaps in osteoarthritis (OA) care are commonly observed, particularly in primary care settings, resulting in many people receiving low-value care. Building workforce capacity to deliver high-value OA care requires a contemporary understanding of barriers to care delivery at multiple levels: at micro (clinical practice and training), meso (service/organisational), and macro (health system) levels. We aimed to explore factors related to OA care delivery across these levels from the perspectives of clinicians and final-year students. Methods: A cross-sectional study sampling clinicians (physiotherapists, primary care nurses, general practitioners (GPs), GP registrars; total possible denominator: n=119,735) and final-year physiotherapy and medical students (denominator: n=2,215) was undertaken across Australia, New Zealand and Canada in 2017. Respondents answered a survey consisting of customised and standard items requiring nominal and free-text responses, from which quantitative and qualitative data, respectively, were derived. At the micro-level we evaluated intrinsic factors (self-perceived confidence in OA knowledge and clinical skills, attitudes towards musculoskeletal pain (measured with Pain Attitudes Beliefs Scale (PABS)), attitudes towards high- and low-value OA care approaches, and the extent to which personal knowledge/skills were barriers to care) and extrinsic factors (use of guidelines in practice and patient-related factors). At the meso-level we explored workplace/clinical placement factors, and at the macro-level, health system factors, as potential barriers to high-value OA care delivery. Quantitative data were analysed using frequency statistics and Bonferroni-corrected general linear models. Content analysis was used to analyse and synthesise qualitative data. Results: 1,886 clinicians (1380 physiotherapists, 158 nurses, 267 GPs, 81 GP registrars) and 1,161 students (465 medical, 696 physiotherapy) responded. At the micro-level, self-rated confidence in OA knowledge and skills was significantly greater in physiotherapists compared to GPs, GP registrars and nurses; in GPs compared to nurses and GP registrars; and in GP registrars compared to nurses. Students’ confidence scores were not different. Biomedical treatment attitudes measured with the PABS were significantly greater in nurses compared to physiotherapists, GPs, and GP registrars; in GPs compared to physiotherapists; in GP registrars compared to physiotherapists and GPs; and in medical students compared to physiotherapy students (Table 1). Some clinicians and students agreed that people with OA ultimately require total joint replacement (7-19% and 19-22%, respectively); that arthroscopy is an appropriate intervention for knee OA (18-36% and 35-44%) and that MRI is informative for diagnosis and clinical management of hip/knee OA (8-61% and 21-52%). Most agreed (90-98% and 92-97%) that exercise is indicated irrespective of the stage of OA. Knowledge and skills gaps were identified as applicable barriers to care delivery by 37-88% of clinicians and 68-85% of students. Meta-synthesis of qualitative data highlighted skills gaps in: specific components of OA care; assessment, measurement and monitoring; tailoring care; managing case complexity; and translating knowledge to practice, especially among students. Extrinsically, patient-related factors and use of guidelines in practice were identified as applicable barriers to care by 49-85% and 14-59% of clinicians, respectively, and 61-71% and 23-53%, respectively, of students. At the meso (workplace)-level, 29-62% of clinicians and 22-51% of students cited barriers to care and qualitative data identified general infrastructure limitations (particularly community facilities) and inconsistent care as the most significant meso-level factors. At the macro (health system)-level, 48-70% of clinicians and 34-37% of students cited barriers to care. Qualitative data identified financing models and time pressures as relevant factors at the macro level. Overall, health system (macro) and patient-related factors (micro) were the most applicable barriers to OA care delivery for clinicians, whereas for students, personal knowledge and skills (micro) and patient-related factors (micro) were the most applicable (Figure 1). Conclusions: Clinicians and students perceived varied barriers to the delivery of high-value care for OA. Improvement strategies therefore need to be directed at all three levels, with a particular focus on closing knowledge and skills gaps at the micro-level and reforming financing models at the macro level.Table 1Summary measures of confidence and attitudes outcomes, reported as mean (SD).OutcomePhysiotherapistsPrimary care nursesGeneral practitionersGeneral practitioner registrarsMedical studentsPhysiotherapy studentsConfidence in OA knowledge [possible score range: 11-55]38.9 (7.0)asignificantly different to all clinical disciplines (p<0.05)29.6 (7.8)asignificantly different to all clinical disciplines (p<0.05)36.8 (6.2)asignificantly different to all clinical disciplines (p<0.05)33.9 (6.1)asignificantly different to all clinical disciplines (p<0.05)34.6 (6.1)35.1 (6.0)Confidence in OA skills [possible score range: 16-80]59.6 (10.2)asignificantly different to all clinical disciplines (p<0.05)45.0 (11.4)asignificantly different to all clinical disciplines (p<0.05)57.2 (8.9)asignificantly different to all clinical disciplines (p<0.05)53.6 (8.7)asignificantly different to all clinical disciplines (p<0.05)54.2 (9.1)53.2 (8.9)PABS-biomed [possible score range: 10-60]28.0 (6.8)asignificantly different to all clinical disciplines (p<0.05)34.9 (5.5)asignificantly different to all clinical disciplines (p<0.05)29.4 (6.0)asignificantly different to all clinical disciplines (p<0.05)32.2 (5.3)asignificantly different to all clinical disciplines (p<0.05)33.4 (5.5)bsignificant difference between student group31.4 (5.8)bsignificant difference between student groupa significantly different to all clinical disciplines (p<0.05)b significant difference between student group Open table in a new tab

Is patient activation associated with changes in symptoms following an osteoarthritis management program?

Is patient activation associated with changes in symptoms following an osteoarthritis management program?

Patterns of endocrine therapy in a national cohort of early stage HER2‐positive breast cancer patients

Guidelines recommend ≥5years of endocrine therapy for hormone receptor-positive breast cancer patients, but nonadherence and treatment discontinuation are common. We examined adherence trajectories and early discontinuation of endocrine therapy over 5years from treatment initiation. Our retrospective cohort study used a national sample of Australian women dispensed publicly subsidised trastuzumab for early HER2-positive breast cancer. We included women initiating endocrine therapy between April 2007 and June 2011, followed until June 2016 (n=2656). We used group-based trajectory modelling and Kaplan-Meier analysis to examine patterns of adherence and time to discontinuation and restarting. We identified five adherence trajectories: quick decline (10.4%), moderate decline (8.6%), quick decline then stable (10.3%), stable with late decline (23.6%), and high and stable (47.2%). Women in the high and stable trajectory group were older and more likely to initiate therapy with anastrozole than women in other groups. Time periods after first 6months, 1.5, and 4years from initiation seemed critical in terms of remaining adherent on endocrine therapy; 45.8% of the cohort discontinued endocrine therapy with a median time to discontinuation of 2.6years (interquartile range 1.0-4.4), and 45.8% of the women discontinuing restarted treatment (median time 182.0, interquartile range 133.0-279.0days). Our study highlights evidence-practice gaps in the use of endocrine therapy, with half of our sample experiencing suboptimal adherence or persistence. Trajectory modelling provided detailed information about patterns of nonadherence and critical time periods for adherence to endocrine therapy. This information is important for developing targeted interventions to improve adherence.

Delirium Monitoring: Yes or No? That Is The Question.

Delirium, one of the most common manifestations of acute brain dysfunction, is a serious complication in patients receiving care throughout the hospital and a strong predictor of worse outcome. Although delirium monitoring is advocated in numerous evidence-based guidelines as part of routine clinical care, it is still not widely and consistently performed at the bedside in different patient care settings. In a debate on delirium monitoring in hospitalized patients at the 7th American Delirium Society meeting in Nashville, Tennessee, June 2017, areas related to the feasibility, acceptability, and effectiveness of routine delirium monitoring of hospitalized patients were identified, and arguments both for (pro) and against (con) the practice were presented. These arguments and others arising in the discussion were subsequently expanded. The goals were to present a conversation among clinicians and researchers from different settings and to identify the evidence-practice gaps for delirium monitoring for future research and organizational quality improvement programs. Further research is needed to determine whether or not delirium monitoring should become routine clinical care for every patient in every hospital setting.