Dissemination Of Guidelines Research Articles

Exploring Stakeholders' Perceptions of the Acceptability, Usability, and Dissemination of the Australian 24-Hour Movement Guidelines for the Early Years.

Australian 24-Hour Movement Guidelines for the Early Years were recently developed. To maximize the uptake of the guidelines, perceptions of key stakeholders were sought. Thirty-five stakeholders (11% Aboriginal or Torres Strait Islander descent) participated in focus groups or key informant interviews. Stakeholders included parents of children aged 0-5 years, early childhood educators, and health and policy professionals, recruited using convenience and snowballing techniques. Focus groups and interviews were audio-recorded and transcribed verbatim. Data were analyzed inductively using thematic analysis. There was general acceptance of the Movement Guidelines. The stakeholders suggested that the Guidelines were highly aspirational and needed to be carefully messaged, so parents did not feel guilty if their child was not meeting them. Stakeholders identified that the messaging needed to be culturally appropriate and visually appealing. Dissemination strategies differed depending on the stakeholder. Seeking stakeholder perceptions is an important process in the development of national Movement Guidelines. This study successfully examined stakeholders' perceptions regarding the acceptability, usability, and dissemination of the Australian 24-Hour Movement Guidelines. Effective and innovative strategies for maximizing compliance and uptake of the Guidelines should be prioritized.

Development of Guidelines to Improve the Effectiveness of Community Advisory Boards in Health Research.

Community advisory boards (CABs) are a common community engagement strategy. Tools for developing CABs that are accessible to academic-community partnerships are limited. This article describes the process and partnership with the Hopi Tribe to develop CAB guidelines as a tool for research funded by the Center for Indigenous Environmental Health Research (CIEHR) and nonaffiliated projects. The CAB guidelines consist of three sections: formation, operation, and sustainability and evaluation. Each section includes best practices and interactive worksheets. The CAB guidelines were piloted with the Hopi Tribe to determine feasibility and relevance. The CAB guidelines were well-received by the tribal CAB. Some of the worksheets were difficult to complete because they did not represent their perspectives or introduced potential tension in CAB interactions. Revisions were made accordingly. Future evaluation and broad dissemination of the CAB guidelines will promote the use and effectiveness of CABs in health research.

Acute Treatment of Pediatric Migraine: A Review of the Updated Guidelines.

The purpose of the Research to Practice column is to review and critique current research articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of M. from their article, "Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society." The authors completed an extensive literature review and created eight recommendations for the acute treatment of pediatric migraine focusing on medication selection, dosing, patient education, and patient counseling. By applying the evidence-based guidelines presented in this study, the urgent care or emergency department APN can confidently recognize and treat acute migraine symptoms and reduce patient risks from unnecessary testing and overuse of acute migraine medications.

Reasons for and barriers to biosafety and biosecurity training in health-related organizations in Africa, Middle East and Central Asia: findings from GIBACHT training needs assessments 2018-2019.

Introductionthe Global-Partnership-Initiated-Biosecurity-Academia for Controlling Health Threats (GIBACHT) consortium conducts a biosafety and biosecurity training for fellows from Africa, the Middle East and Asia. To achieve a multiplier effect, fellows conduct trainings in their own organizations. It was during such trainings that training needs assessments were done assessing reasons for and barriers to biosafety and biosecurity training.Methodsthis was a cross sectional assessment. Trainings were conducted from April to July 2018 and April to June 2019. In 2018, training needs were explored using a structured tool. Responses were coded using manifest content analysis and key issues identified. In 2019, respondents quantified the identified key issues using a Likert scale. Proportions of those who strongly agreed, agreed, neither agreed nor disagreed, disagreed or strongly disagreed were calculated and results presented in tables and charts.Resultsin 2018 and 2019, there were 183 and 191 respondents respectively. About 96% of respondents in 2018 supported training in biosafety and biosecurity citing individual, community and global benefits. Barriers highlighted included governance, financial, human resource, information and infrastructure challenges. In 2019, majority of respondents indicated inadequate guidelines dissemination, lack of financial resources, inadequate personnel, lack of equipped laboratories and lack of instructional materials among major barriers.Conclusionsupport for biosafety and biosecurity training was high though systemic barriers exist. Improving human resource capacity and provision of instructional materials can be achieved through training programs. However, systemic assessments need to be done before each training as different organizations have different barriers.

An Overview of Strategies Targeting Inappropriate Advanced Diagnostic Imaging in the Setting of Acute Uncomplicated Low Back Pain

The aims of this article are to review the driving forces for increased utilization of imaging within the US and to review the strategies currently being implemented to curtail the use of inappropriate advanced diagnostic imaging (ADI) in the setting of acute uncomplicated low back pain. Strategies aimed at reducing inappropriate ADI in the setting of uncomplicated low back pain, including guideline dissemination, clinical decision support (CDS), audit and feedback, prior authorization, and prior notification. Increasing utilization of inappropriate ADI is a multifactorial problem, and the solution is complex. Like many problems in medicine, it is unlikely that we will be able to identify a single intervention as a solution. Instead, a concerted effort grounded in physician education, CDS, and audit and feedback may be our best tool against inappropriate ADI in the setting of acute uncomplicated low back pain.

Do obstetricians apply the national guidelines? A vignette-based study assessing practices for the prevention of preterm birth.

To describe spontaneous preterm birth prevention practices self-reported before and after the dissemination of relevant guidelines, and to identify personal and organisational factors associated with adherence. A repeated cross-sectional vignette-based survey study. French obstetricians. French obstetricians practicing in public or private maternity units. Before and after the dissemination of the 2017 French guidelines on the prevention of spontaneous preterm birth, participants were asked to complete a web-based self-administered questionnaire based on two clinical vignettes. Vignette 1 focused on respondents' attitudes towards strict bed rest, cerclage, and progesterone treatment for women with a short cervix in mid-trimester; vignette 2 focused on attitudes towards strict bed rest and maintenance tocolysis after successful tocolysis for preterm labour. A mixed quantitative and qualitative analysis was conducted. Non-adherence to guidelines for the prevention of spontaneous preterm birth in responses to each vignette. We obtained complete responses from 286 obstetricians before and 282 obstetricians after guideline dissemination, including 145 obstetricians participating in both. After dissemination, 51.4% of obstetricians self-reported non-adherent practices for vignette 1 and 22.3% of obstetricians self-reported non-adherent practices for vignette 2. No improvement was observed after dissemination. The quantitative analysis identified factors associated with non-adherence, including older age and practice in non-university or small hospitals, whereas the qualitative analysis highlighted barriers to implementation, including fear of change, habits, work overload, and lack of time. Adherence to guidelines was generally low, with practices unmodified by their dissemination. Improvement is required, especially regarding applicability. Adherence to guidelines to prevent spontaneous preterm birth was generally low and remained unmodified after guideline dissemination.

Dissemination and implementation of strategy adoption guidelines for persons with dementia at risk of getting lost

Objectives To address risks associated with critical dementia-related wandering, three guidelines were developed for use by persons living with dementia, their care partners, and professional staff, to choose wander-management strategies. This evidence-based research incorporates knowledge mobilization approaches that directly involve the three types of stakeholders in using the guidelines in the real world. The purpose of this project was to evaluate the knowledge translation of three guidelines on wander-management strategies, and to further deploy these guidelines to organizations across Canada. Methods Steering committees across Canada were established for consultation. Guidelines were then shared among these organizations via Google slides. Health professionals, caregivers, community organizations and persons living with dementia completed an online survey (via Google) or paper-based survey to provide feedback on the guidelines. The guidelines were then translated from English to French using a forward-translation method. Results The guidelines were adopted across ten organizations in four Canadian provinces. Adoption included introduction and formal training to staff. It took 22 months from the development of the guidelines to the dissemination and launch of the guidelines to the organizations. Participants (n = 73) were very satisfied with the developed guidelines and agreed they were easy to navigate, easy to understand, and the information provided was useful. Conclusions A stakeholder-driven approach used for guideline development and dissemination were successful methods for minimizing the time for this work to become practice. This in addition to the use of online platforms can replace conventional methods which take longer and become quickly outdated.

Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

In the Special Article “Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society,” by Oskoui et al.,1 the following disclaimer/publication statement should have been included: “These guidelines were jointly developed by the American Academy of Neurology Institute and American Headache Society. This article was peer reviewed and first published by Neurology , and subsequently published in Headache .” The publisher regrets the error.

Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

In the Special Article “Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society” by Oskoui et al.,1 the following disclaimer/publication statement should have been included: “These guidelines were jointly developed by the American Academy of Neurology Institute and American Headache Society. This article was peer reviewed and first published by Neurology , and subsequently published in Headache .” The publisher regrets the error.

Effectiveness and cost-effectiveness of a multicomponent intervention to implement a clinical practice guideline for systemic lupus erythematosus: protocol for a cluster-randomized controlled trial

BackgroundSystemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with significant potential morbidity and mortality. Substantial gaps have been documented between the development and dissemination of clinical practice guidelines (CPG) and their implementation in practice. The aim of this study is to assess the effectiveness and cost-effectiveness of a multi-component knowledge transfer intervention to implement a CPG for the management of SLE (CPG-SLE).MethodsThe study is an open, multicentre, controlled trial with random allocation by clusters to intervention or control. Clusters are four public university hospitals of the Canary Islands Health Service where rheumatologists are invited to participate. Patients diagnosed with SLE at least one year prior to recruitment are selected. Rheumatologists in intervention group receive a short educational group programme to both update their knowledge about SLE management according to CPG-SLE recommendations and to acquire knowledge and training on use of the patient-centred approach, a decision support tool embedded in the electronic clinical record and a quarterly feedback report containing information on management of SLE patients. Primary endpoint is change in self-perceived disease activity. Secondary endpoints are adherence of professionals to CPG-SLE recommendations, health-related quality of life, patient perception of their participation in decision making, attitudes of professionals towards shared decision making, knowledge of professionals about SLE and use of healthcare resources. Calculated sample size is 412 patients. Data will be collected from questionnaires and clinical records. Length of follow-up will be 18 months. Multilevel mixed models with repeated time measurements will be used to analyze changes in outcomes over time. Cost-effectiveness, from both social and healthcare services perspectives, will be analyzed by measuring effectiveness in terms of quality-adjusted life years gained. Deterministic and probabilistic sensitivity analyses are planned.DiscussionImpact of CPGs in clinical practice could be improved by applying proven value interventions to implement them. The results of this ongoing trial are expected to generate important scientifically valid and reproducible information not only on clinical effectiveness but also on cost-effectiveness of a multi-component intervention for implementation of a CPG based on communication technologies for chronic patients in the hospital setting.Trial registrationClinicalTrial.gov NCT03537638. Registered on 25 May 2018.

Peripheral Arterial Disease Prevention in Women: Awareness and Action.

Peripheral Arterial Disease Prevention in Women: Awareness and Action.

\u2018Weighty issues\u2019 in GP-led antenatal care: a qualitative study

BackgroundApproximately 50% of women gain weight in excess of gestational weight gain (GWG) recommendations during pregnancy leading to adverse maternal and foetal outcomes and the perpetuation of the cycle of obesity. Antenatal care provided by a general practitioner (GP) in the primary care setting is an important model of care, particularly for women in regional areas where rates of overweight and obesity are highest. The aim of this study is to explore GPs’ perceptions and experiences of implementing GWG recommendations in GP-led antenatal care.MethodsA qualitative exploratory approach recorded GPs’ experiences and insights regarding the application of GWG recommendations in practice. Data were collected via semi-structured interviews informed by the revised Theoretical Domains Framework (TDF). Deductive thematic analysis grouped coded text into TDF domains from which main themes were generated.ResultsTwenty GPs (13 female, 7 male) from metropolitan and regional Victoria, Australia participated. Codes related to at least one of 11 TDF domains. Five main themes were apparent: 1) Despite low awareness of guidelines, GWG advice is provided; 2) ‘I should do this more’; 3) Lack of everyday resources; 4) Working ‘against the odds’ at times; and 5) Optimism and reality. GPs were aware of the importance of optimal GWG however, other pregnancy-related issues are given precedence during consultations. Enablers for the implementation of GWG guidelines were practitioner-based and included GPs’ strong sense of their professional role to provide advice, and ongoing and trusting relationships with women throughout pregnancy. Barriers were mostly health system-based with limited time, remuneration, and restrictive referral pathways being limiting factors.ConclusionsThere is a need to support GPs to provide GWG advice in accordance with current national guidelines. Solutions potentially lie in strategies that promote the effective dissemination and uptake of guidelines, and changes to policy and funding within the health-system so that longer GP-led antenatal care consultations are remunerated and referrals to allied health are accessible to women who require additional support to optimise GWG.

1881. The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use: Results From a National Antibiotic Stewardship Intervention of 402 United States (US) Hospitals

BackgroundThe AHRQ Safety Program for Improving Antibiotic Use aims to improve antibiotic (abx) use in acute, long-term, and outpatient care settings by enhancing abx stewardship programs (ASP) and engaging frontline providers to incorporate stewardship into daily abx decision-making, with an emphasis on viewing appropriate prescribing as a patient safety issue. We report on the impact of implementation of the Acute Care Safety Program on abx use and Clostridioides difficile in a cohort of US hospitals.MethodsThe Acute Care Safety Program was implemented from December 2017 to November 2018. At least one unit from each hospital participated. The Safety Program trained local ASP leaders and assisted ASPs and frontline staff to: (a) address attitudes and culture that pose challenges to judicious abx use and (b) incorporate best practices for the management of common infections into daily practice using the Four Moments of Antibiotic Decision Making framework (Figure 1). Education occurred via 17 live Webinars and an online toolkit that included recorded Webinars, narrated presentations, and other tools to assist with the development and dissemination of syndrome-specific local guidelines (Table 1). Units submitted days of abx therapy (DOT) per 1,000 patient-days (PD), C. difficile LabID events per 10,000 PD, and 10 review forms per month documenting structured discussions between the ASP and frontline staff about patients on abx. Linear and generalized linear mixed-effects models were employed to calculate pre-post intervention changes in abx use and C. difficile LabID events, respectively.Results402 hospitals completed the Safety Program, including 28 (7%) academic medical centers (AMC), 289 (72%) community hospitals, and 85 (21%) critical access hospitals. 476 participating units consisted of 165 (35%) ICUs, 300 (63%) medical-surgical floors, and 11 (2%) other units. Both abx use and C. difficile LabID events decreased when comparing pre-post data (−41 DOT per 1,000 PD, [from 886.56, Figure 2], P = 0.001 and −1.2 LabID events per 10,000 PD [from 6.3], P = 0.027), respectively.ConclusionBy targeting both improving abx prescribing culture and knowledge of best practices, the AHRQ Safety Program led to reductions in abx use across a diverse cohort of hospitals. DisclosuresSara E. Cosgrove, MD, MS, Basilea: Consultant; Theravance: Consultant.

1987. Impact of Updated IDSA Clostridium difficile Guidelines on the use of Fidaxomicin in a Large Health System

BackgroundFidaxomicin (fidax) is approved for treatment of Clostridioides difficile infection. In February 2018 IDSA/SHEA released updated guidelines suggesting expanded use of fidax, recommending it or oral vancomycin (po vanc) in severe or non-severe initial episodes or for most recurrences. In April 2018, University of Pittsburgh Medical Center (UPMC) relaxed system-wide guidelines to allow for fidax use in the first recurrence of C. difficile or later, with earlier use allowed by ID or GI specialists or with local Pharmacy and Therapeutics Chair approval. Hospitals could continue to be more restrictive if desired. We reviewed changes in fidax, po vanc, and IV/PO metronidazole (metro) use at UPMC hospitals after guideline changes.MethodsFor the reviewed antibiotics, hospital-level usage was evaluated at 15 UPMC hospitals before/after system-level changes. Usage was measured as days of therapy per 1,000 patient-days (DOT/1,000 PD). Sites were further grouped by the level of restrictions: Standard (following new system guidelines) or more restrictive (additional restrictions remained in place locally). Hospitals were also grouped by type of local stewardship programs (ASP): Robust (included an Infectious Diseases trained clinical pharmacist or ID physician with specific time dedicated to antibiotic review) or Non-Robust.ResultsFigure 1 shows before/after changes in usage at all hospitals. Figure 2 shows changes in Standard vs. More Restrictive hospitals, and Figure 3 shows changes in Robust vs. Non-Robust hospitals.ConclusionFidax use remained low, but an increase was seen after the release of the guidelines and relaxation of system restrictions, mainly in hospitals without additional restrictions in place. PO vanc also increased across the system, possibly indicating better adherence to updated guidelines regarding less metro use for C. difficile treatment. Although minimal decrease, if any, was seen with metro itself. This could have been compounded by the recent fluid shortage as well as other common uses for metro. Dissemination of new guidelines to providers should be a key function of ASPs as well as monitoring for changes in usage after implementation of local changes. Further studies are needed to define any differences in practice patterns and clinical outcomes related to changes in guidelines. Disclosures All authors: No reported disclosures.

525. Evaluation of Implementation of Guidelines for Carbapenem-resistant Enterobacteriaceae (CRE) Prevention Using the Consolidated Framework for Implementation Research (CFIR)

BackgroundInfections caused by carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing (CP) CRE are difficult to treat, resulting in a high mortality annually. In 2017, VA released guidelines for CRE/CP-CRE laboratory testing, prevention, and management. We used the Consolidated Framework for Implementation Research (CFIR) to understand factors influencing implementation of the CRE guideline at VA Medical Centers (VAMCs).MethodsBetween 9/17–8/18, 43 semi-structured interviews were conducted with Multi-Drug Resistant Organism Program Coordinators, laboratorians, physicians and infection preventionists from 29 geographically representative VAMCs of varying size and CP-CRE burden. Interviews addressed perceptions of guideline dissemination, laboratory testing, training, patient education, and IT support (e.g., CRE/CP-CRE flag, lab report and template). We analyzed transcripts using a consensus-based mixed deductive-inductive coding approach to identify CFIR constructs, best practices, recommendations/feedback and implementation challenges.Results95% of interviewees reported using VA CRE/CP-CRE guidelines, most (79%) with high confidence. Respondent comments (n = 798) were coded using CFIR constructs [Inner Setting (e.g., resources), (48%); Process (e.g., planning), (23%); Intervention Characteristics (e.g., VA guidelines) (17%); Outer Setting (e.g., patient needs) (6%); Characteristics of Individuals (e.g., self-efficacy) (6%)]. Interviewees also described Best Practices (15%) and Feedback/Recommendations (12%) including the need for improved lab testing/reporting, communication, contact isolation, staff training, patient education and cost.ConclusionOur results suggest sustained improvement in multiple areas to facilitate guideline implementation to identify, prevent, and manage CRE/CP-CRE are needed. This is critical because CRE/CP-CRE incidence and mortality rates are projected to increase. Disclosures All authors: No reported disclosures.

Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.

In the special article “Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology,” …

Editors' note: Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

In the special article “Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis,” Rae-Grant et al. reported the findings of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology based on reviewing the evidence on starting, switching, and stopping disease-modifying therapies for clinically isolated syndrome, relapsing-remitting MS, and progressive forms of MS. In response, Dr. Tran, on behalf of Genentech, argues that the report did not make it clear that data on annualized relapse rate reduction and relative risk of in-study disability progression for ocrelizumab (presented along with other therapies in figures 1 and 3) were from direct comparisons with subcutaneous interferon-β-1a 44 μg 3 times weekly in 2 phase 3 randomized, double-blind, double-dummy trials. In response, Dr. Rae-Grant agrees that this information should have been included, but notes that statements in the text of the summary and in a key accompanying table acknowledged the superior efficacy of ocrelizumab compared with interferon- β-1a 3 times weekly. Dr. Rae-Grant also notes that data on subgroup analysis of treatment of highly active MS with ocrelizumab were not available at the time of publication of the systematic review. In the special article “Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis,” Rae-Grant et al. reported the findings of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology based on reviewing the evidence on starting, switching, and stopping disease-modifying therapies for clinically isolated syndrome, relapsing-remitting MS, and progressive forms of MS. In response, Dr. Tran, on behalf of Genentech, argues that the report did not make it clear that data on annualized relapse rate reduction and relative risk of in-study disability progression for ocrelizumab (presented along with other therapies in figures 1 and 3) were from direct comparisons with subcutaneous interferon-β-1a 44 μg 3 times weekly in 2 phase 3 randomized, double-blind, double-dummy trials. In response, Dr. Rae-Grant agrees that this information should have been included, but notes that statements in the text of the summary and in a key accompanying table acknowledged the superior efficacy of ocrelizumab compared with interferon- β-1a 3 times weekly. Dr. Rae-Grant also notes that data on subgroup analysis of treatment of highly active MS with ocrelizumab were not available at the time of publication of the systematic review.

Author response: Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.

To review evidence on starting, switching, and stopping disease-modifying therapies (DMTs) for multiple sclerosis (MS) in clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), and progressive MS forms.Relevant, peer-reviewed research articles, systematic reviews, and abstracts were identified (MEDLINE, CENTRAL, EMBASE searched from inception to November 2016). Studies were rated using the therapeutic classification scheme. Prior published Cochrane reviews were also used.Twenty Cochrane reviews and an additional 73 full-text articles were selected for data extraction through an updated systematic review (completed November 2016). For people with RRMS, many DMTs are superior to placebo (annualized relapses rates [ARRs], new disease activity [new MRI T2 lesion burden], and in-study disease progression) (see summary and full text publications). For people with RRMS who experienced a relapse on interferon-β (IFN-β) or glatiramer acetate, alemtuzumab is more effective than IFN-β-1a 44 μg subcutaneous 3 times per week in reducing the ARR. For people with primary progressive MS, ocrelizumab is probably more effective than placebo (in-study disease progression). DMTs for MS have varying adverse effects. In people with CIS, glatiramer acetate and IFN-β-1a subcutaneous 3 times per week are more effective than placebo in decreasing risk of conversion to MS. Cladribine, immunoglobulins, IFN-β-1a 30 μg intramuscular weekly, IFN-β-1b subcutaneous alternate day, and teriflunomide are probably more effective than placebo in decreasing risk of conversion to MS. Suggestions for future research include studies considering comparative effectiveness, usefulness of high-efficacy treatment vs stepped-care protocols, and research into predictive biomarkers.

Tracking Opioid Prescribing Metrics in Washington State (2012-2017): Differences by County-Level Urban-Rural and Economic Distress Classifications.

High-risk opioid prescribing is a critical driver of prescription opioid-related morbidity and mortality. This study explored opioid prescribing patterns across urban-rural and economic distress classifications. Secondarily, this study explored the urban-rural distribution of relevant health services, economic factors, and population characteristics. County-level opioid prescribing metrics were based on quarterly Washington State Prescription Monitoring Program data (2012-2017). Counties were classified using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties, and Washington State unemployment-based distressed areas. County-level measures from Area Health Resources Files were used to describe the urban-rural continuum. Persistent economic distress was associated with higher-risk opioid prescribing. The large central metropolitan category had lower-risk opioid prescribing metrics than the other 5 urban-rural categories, which were similar to each other and not ordered by degree of rurality. High-risk prescribing declined over time, without notable trend divergence by either urban-rural or economic distress classifications. The most striking urban-rural differences in opioid prescribing metrics were between large central metropolitan and all other categories; thus, we recommend caution when collapsing urban-rural categories for analysis. Further research is needed regarding geographic and economic patterning of opioid prescribing practices, as well as the dissemination of guidelines and best practices across the urban-rural continuum. Finally, the multiple intertwined burdens faced by rural communities-higher-risk prescribing practices, higher opioid morbidity and mortality rates, and fewer resources for primary care, mental health care, alternative pain treatment, and opioid use disorder treatment-must be addressed as an urgent public health priority.

Deep renovation of historic buildings

Purpose Improving the energy performance of historic buildings has the potential to reduce carbon emissions while protecting built heritage through its continued use. However, implementing energy retrofits in these buildings faces social, economic, and technical barriers. The purpose of this conceptual paper is to present the approach of IEA-SHC Task 59 to address some of these barriers. Design/methodology/approach Task 59 aims to achieve the lowest possible energy demand for historic buildings. This paper proposes a definition for this concept and identifies three key socio-technical barriers to achieving this goal: the decision-makers’ lack of engagement in the renovation of historic buildings, a lack of support during the design process and limited access to proven retrofit solutions. Two methods – dissemination of best-practice and guidelines – are discussed in this paper as critical approaches for addressing the first two barriers. Findings An assessment of existing databases indicates a lack of best-practice examples focused specifically on historic buildings and the need for tailored information describing these case studies. Similarly, an initial evaluation of guidelines highlighted the need for process-oriented guidance and its evaluation in practice. Originality/value This paper provides a novel definition of lowest possible energy demand for historic buildings that is broadly applicable in both practice and research. Both best-practices and guidelines are intended to be widely disseminated throughout the field.