Multifaceted Educational Intervention Research Articles

Improving Family Medicine Residents' Provision of Gender-Affirming Care.

Family physicians are uniquely poised to provide gender-affirming care (GAC) to transgender and nonbinary patients, but current undergraduate and graduate medical education in this field is lacking. Little is known about the impact of various GAC curricula on the clinical care provided by resident physicians. We aimed to assess the efficacy of a multimodal educational framework on the quality of GAC provided by residents at a large academic family medicine program. This pilot study used chart review to assess the impact of a multifaceted educational intervention around GAC in an academic family medicine practice. Components included faculty-specific didactics, resident feedback and didactics, standardized note templates, and compiled resources. We completed pre- and postintervention analysis of resident-led GAC encounters using a novel rubric based on standards of care and compared these results using descriptive statistics. Following a multimodal educational intervention, residents demonstrated improvement in multiple domains of gender-affirming care, including documenting informed consent, counseling on pregnancy and contraception, and laboratory monitoring for patients initiating gender-affirming hormone therapy. This widespread improvement suggested that a multimodal approach to resident and faculty education may help enhance the quality of GAC provided by family medicine residents. Chart review offers a feasible and effective method for identifying gaps in resident knowledge and documentation in GAC. Further research should specifically explore faculty development in this area and expanded patient-centered quality metrics and outcomes that encompass GAC.

1853 Improving treatment for urinary tract infections for older adults in the Health and Ageing Unit

Abstract Introduction A suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Therefore, correct recognition and documentation of UTIs, as well prescribing of antibiotics, is important for optimising patient care. Methods We reviewed UTI antibiotic prescribing practice across the Health and Ageing Unit (HAU) wards at Kings College Hospital over a two-month period. Weekly data we collected from all patients commenced on antibiotics for a suspected UTI highlighted key areas for improvement. We designed and delivered a multifaceted educational intervention to all healthcare professionals caring for older adults across the HAU. This consisted of teaching sessions, distribution of posters, and board round reminders. Results A further two months of data post-intervention showed improvements in several outcomes. Correct prescribing rose from 61% to 93%. The number of prescriptions with stop dates went up from 50% to 68%. The number of patients with urine samples processed in the laboratory rose from 64% to 93%. We also saw an improvement in the management of patients with catheter associated UTIs. Conclusions A multidisciplinary team intervention of teaching and visual cues improved the management of UTIs. This shows the power of multifaceted educational interventions for improving the care of older adults.

CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice – how did it bring about behaviour change?

BackgroundThere is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia’s online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future.MethodsThis mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework.ResultsOf the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs’ perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions.ConclusionsOur education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).

The Effects of a Nutritional Education Package Titled "Eat a Rainbow Every Day" on Eating Behaviors and Physical Activity of Elementary School Children

Background: In school age children, a healthy nutritional behavior can prevent double burden of malnutrition and chronic diseases. Nutritional education has a key role in adopting a healthy lifestyle. This study aims to evaluate the effectiveness of an educational package on the nutritional knowledge and practices, physical activity (PA), and body mass index (BMI) of elementary school children in Zahedan, southeast Iran. Methods: In this quasi-experimental before-after study, a total of 734 elementary school children‎, aged 10–14 years, recruited by census sampling method completed the survey. Each student received 8 hours of training and they were provided with a booklet that included a weekly chart for recording intake of food groups and PA by students for 3 months. A semi-structured questionnaire that included questions on the students' nutritional knowledge, eating behavior, PA performance, and BMI before and after the intervention was used for data collection. Paired t-test, McNemar's, and Friedman tests were used for data analysis. Results: Before the intervention, the mean score of nutritional knowledge was 7.5 and the prevalence of underweight and overweight/obesity was 17.4% and 0.4%, respectively. After the intervention, the results showed a significant increase in the nutritional knowledge scores, the number of days with 30 min PA per week, and the frequency of consumption of dairy products, animal protein, and fruits. Also, in comparison with before intervention, a significant decrease was found in the prevalence of underweight and overweight/obesity of school children after the intervention. Conclusion: This multifaceted nutritional education intervention was associated with improved nutritional knowledge score, PA, and being underweight in elementary school children.

Improving the quality of written communication at patient discharge: triangulation of qualitative analyses and intervention co-design

BackgroundPoor handovers between hospital and primary care threaten safe discharges, with elderly and frail patients most at risk of harm. Using Behavioural Science we explored influences and identified relevant behaviour change techniques (BCTs) to improve written handovers and safety during discharge. MethodsWe conducted two qualitative studies: (1) ethnographic observations (>80 h) collected by five researchers in five purposively sampled clinical areas of a London teaching hospital, investigating routine work and interactions of hospital staff involved in discharges; and (2) 12 semi-structured interviews with hospital staff involved in discharge exploring influences on preparations of written handovers. Written consent was sought from clinical leads for ethnographic observations and from interview participants. Ethnographic fieldnotes and interview transcripts were thematically analysed using inductive and deductive approaches, respectively. Study findings were triangulated to identify key influences, mapped onto the Theoretical Domains Framework (TDF). We identified appropriate BCTs to address observed influences within each TDF domain using the Theory and Techniques Tool. Health-care workers (n=15), patients (n=2) and carers (n=2) selected and designed an intervention to improve written handovers in two workshops. Hospital workshop participants were involved with preparing written discharge handovers. Public participants had either recently been discharged from hospital or cared for someone recently discharged, including patients from groups especially vulnerable during discharge. FindingsTriangulation of study findings generated 11 key influences on preparations of written handovers within five TDF domains: knowledge (eg, lack of awareness of guidelines), skills (staff experience), social or professional role and identity (effective communication), environmental context and resources (working patterns), and social influences (lack of feedback). 14 BCTs were identified to address these influences, including behavioural rehearsal or practice, instruction on how to perform a behaviour, and social support (practical). Workshop participants selected and designed a multifaceted educational intervention to improve written handovers. InterpretationThe quality of handover documentation prepared by hospital staff for primary care teams is affected by influences from multiple domains, requiring a multifaceted approach to improve handovers. Although only based on findings from one hospital, the designed intervention should be tested in clinical settings with key stakeholders, including primary care staff, to evaluate impact on quality of written handovers and patient safety. FundingNational Institute for Health and Care Research (NIHR) Imperial Patient Safety Translational Research Centre.

A Multifaceted Educational Intervention in the Doctor-Patient Relationship for Medical Students to Incorporate Patient Agendas in Simulated Encounters.

From the beginning of their clinical training, medical students demonstrate difficulties when incorporating patient perspectives. This study aimed to assess if students, after an instructional programme, increased their sensitivity towards patients' needs and carried out bidirectional conversations. An observational study involving 109 medical students prior to their clerkships was designed. They attended a five-step training programme designed to encourage the use of communication skills (CSs) to obtain patients' perspectives. The course developed experiential and reflective educational strategies. The students improved their use of CSs throughout three sessions, and the overall score for these patient consultations went up in the opinions of both the external observer (EO) (5; 6.6; 7.5) and the simulated patients SPs (5.3; 6.6; 7.8). Most of the students (83.9%) considered that the CSs addressed were useful for clinical practice, particularly the interviews and the feedback received by the SP and the lecturer. The programme seems to help the students use CSs that facilitate a more bidirectional conversation in a simulated learning environment. It is feasible to integrate these skills into a broader training programme. More research is needed to assess whether the results are applicable to students in real settings and whether they influence additional outcomes.

Using Codesign to Develop a Novel Oral Healthcare Educational Intervention for Undergraduate Nursing Students

To build a nursing workforce that is equipped to undertake oral health promotion and screening, an educational program was needed. With codesign being used in multiple settings, it was selected as the approach to use, with Mezirow's Transformative Learning theory as the underpinning framework. This study aimed to develop an oral healthcare educational intervention for nursing students. Using a six-step codesign framework, nursing students and faculty staff were invited to participate in two Zoom™ Video Communication workshops to codesign the learning activities to be used in the classroom. The codesign process was evaluated through focus groups and analysed using a hybrid content analysis approach. A multifaceted oral healthcare educational intervention was developed. Learning material was delivered using a range of different learning and teaching resources such as dental models, podcasts, and an oral health assessment across two subjects. Multiple approaches to recruitment, the inclusion of participants, and good facilitation of workshop discussions were critical to the codesign of the educational intervention. Evaluation revealed that preparing participants prior to the workshops acted as a catalyst for conversations, which facilitated the codesign process. Codesign was a useful approach to employ in the development of an oral healthcare intervention to address an area of need.

Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022)

BackgroundDiarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.MethodsWe describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother–child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother–child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.ConclusionsThe trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.Trial registrationISRCTN14390796. Registration date December 13, 2021

A Multifaceted Educational Intervention to Reduce Plasma Utilization

Blood transfusion services maintain quality practice through adherence to guidelines but are faced with blood component wastage due to multiple factors. One factor, in particular, is poor ordering and utilization practices followed by physicians who may not be familiar with the indications and the optimal conditions for the handling of blood products. This study evaluates whether an educational intervention would help reduce ordering of plasma and improve wastage rates after thawing. The study followed a quasi-experimental pre-test post-test design. A multifaceted educational intervention was introduced at a tertiary hospital-based combining predisposing, enabling, and reinforcing activities, based on the literature of effective continuous professional development. The activities included a brief survey to evaluate participant knowledge about indications of plasma and its storage condition, a lecture, and periodic reports and reminders sent to all department heads in the hospital. Respondents to the survey and lecture attendees included physicians in adult critical care and anesthesia departments. Monthly plasma utilization and wastage rates were compared before and after introducing the intervention. Sixty physicians participated in the survey. The questions were answered correctly by less than half. After introducing the intervention, monthly plasma transfusion rates decreased; however, wastage rates did not improve. There is a knowledge gap among physicians who order plasma. The educational intervention resulted in lower plasma transfusion rates but did not affect wastage rates. Future interventions would benefit from including physicians in other departments as well as nurses.

BLITZ-HF: a nationwide initiative to evaluate and improve adherence to acute and chronic heart failure guidelines.

To assess adherence to guideline recommendations among a large network of Italian cardiology sites in the management of acute and chronic heart failure (HF) and to evaluate if an ad-hoc educational intervention can improve their performance on several pharmacological and non-pharmacological indicators. BLITZ-HF was a cross-sectional study based on a web-based recording system with pop-up reminders on guideline recommendations used during two 3-month enrolment periods carried out 3 months apart (Phase 1 and 3), interspersed by face-to-face macro-regional benchmark analyses and educational meetings (Phase 2). Overall, 7218 patients with acute and chronic HF were enrolled at 106 cardiology sites. During the enrolment phases, 3920 and 3298 patients were included, respectively, 84% with chronic HF and 16% with acute HF in Phase 1, and 74% with chronic HF and 26% with acute HF in Phase 3. At baseline, adherence to guideline recommendations was already overall high for most indicators. Among acute HF patients, an improvement was obtained in three out of eight indicators, with a significant rise in echocardiographic evaluation. Among chronic HF patients with HF and preserved or mid-range ejection fraction, performance increased in two out of three indicators: creatinine and echocardiographic evaluations. An overall performance improvement was observed in six out of nine indicators in ambulatory HF with reduced ejection fraction patients with a significant increase in angiotensin receptor-neprilysin inhibitor prescription rates. Within a context of an already elevated level of adherence to HF guideline recommendations, a structured multifaceted educational intervention could be useful to improve performance on specific indicators. Extending this approach to other non-cardiology healthcare professionals, who usually manage patients with HF, should be considered.

How to improve hospital admission screening for patients at risk of multidrug-resistant organism carriage: a before-and-after interventional study and cost-effectiveness analysis

BackgroundInfection prevention and control (IPC) is a prioritised task for healthcare workers in emergency department (ED). Here, we examined compliance with admission screening (AS) and additional precautions (AP) measures for...

A multifaceted educational intervention improved anti-infectious measures but had no effect on mortality in patients with severe sepsis

Sepsis is a major reason for preventable hospital deaths. A cluster-randomized controlled trial on an educational intervention did not show improvements of sepsis management or outcome. We now aimed to test an improved implementation strategy in a second intervention phase in which new intervention hospitals (former controls) received a multifaceted educational intervention, while controls (former intervention hospitals) only received feedback of quality indicators. Changes in outcomes from the first to the second intervention phase were compared between groups using hierarchical generalized linear models controlling for possible confounders. During the two phases, 19 control hospitals included 4050 patients with sepsis and 21 intervention hospitals included 2526 patients. 28-day mortality did not show significant changes between study phases in both groups. The proportion of patients receiving antimicrobial therapy within one hour increased in intervention hospitals, but not in control hospitals. Taking at least two sets of blood cultures increased significantly in both groups. During phase 2, intervention hospitals showed higher proportion of adequate initial antimicrobial therapy and de-escalation within 5 days. A survey among involved clinicians indicated lacking resources for quality improvement. Therefore, quality improvement programs should include all elements of sepsis guidelines and provide hospitals with sufficient resources for quality improvement.Trial registration: ClinicalTrials.gov, NCT01187134. Registered 23 August 2010, https://www.clinicaltrials.gov/ct2/show/study/NCT01187134.

Enhancing Knowledge of Family Caregivers and Quality of Life of Patients with Ischemic Stroke

Objectives: A Quasi-Experimental study was conducted to determine the impact of Attend-trial-based interventions on the knowledge of the caregivers and the quality of life of Ischemic stroke survivors.
 Material and Methods: The study was conducted in the acute care hospital located in the rural area, Khyber Pukhtoonkha. A sample of 115 patients and informal caregivers participated in a multifaceted intervention including educational sessions, training and demonstration, and post-training discussion via WhatsApp. A pre-post evaluation of the quality of life, stroke knowledge, functioning, and activities of daily living was completed using validated tools. All information was collected using predesign pro forma and questionnaire.
 Results: The interventions significantly improved all four outcomes in caregivers and patients. The mean score for the WHOQOL-BREF pre-intervention was 2.91 ± 1.10 which was increased to 4.18 ± 0.86. The pre-knowledge scores were 34.00 which increased to 39.95. There was a statistically significant change between pre and post knowledge scores [t (114) = -3.394, p = 0.001].
 Conclusion: The study contributed towards the usefulness of multifaceted education intervention to enhance the rehabilitation efforts of patients and their caregivers in community settings.

A successful intervention to improve medication adherence in Black patients with hypertension: Mediation analysis of 28-site TEAM trial

BackgroundWe previously reported the main effects and cost-effectiveness of a successful multifaceted Team Education and Adherence Monitoring (TEAM) intervention to improve refill adherence in Black patients with hypertension. It is important to identify the key mediators or intervention components that contributed to this intervention effect. ObjectivesThis study aimed to conduct a “mediation analysis” to determine which intervention components had the largest effect on refill adherence and assess patient satisfaction with pharmacy care. MethodsA cluster-randomized trial was conducted among 576 Black patients in 28 pharmacies (14 TEAM, 14 control). TEAM participants were invited to 6 visits with a pharmacist-technician team that monitored the patient’s blood pressure and used a 9-item Brief Medication Questionnaire, Brief Goal Check, and other novel tools to identify and reduce barriers to adherence in Black patients. Control participants received printed information only. Refill adherence was defined as >80% days covered (proportion of days covered) per refill records during months 7 to 12 (postintervention); potential mediators and patient satisfaction were assessed using a research questionnaire administered at month 6. A structural probit model examined 4 potential mediators that might explain intervention success. ResultsOf 4 potential mediators, the most important factors in explaining the improvement in refill adherence (postintervention) were greater pharmacist collaboration with patient in barrier reduction (68.5% of total indirect effect) and patient use of a pillbox (27.2% of total indirect effect). Pharmacist contact with physician and suggestion of a change in regimen did not have significant effects on adherence. TEAM participants were more likely than control participants to rate their pharmacist care as “very satisfactory” (80.2% vs. 44.2%, P < 0.001) and technician care as “very satisfactory” (81.2% vs. 47.4%, P < 0.001). ConclusionRefill adherence and satisfaction can be improved in Black patients with hypertension by implementing a collaborative TEAM model with novel tools that enable community pharmacists and technicians to help identify and reduce the core barriers to adherence. Our results can be used to individualize and improve patient care and adherence outcomes in this vulnerable population.

Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections.

Background Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting.MethodsThis stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys.ResultsA total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79–13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93–14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups.ConclusionsMultifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.

Implementation of clinical practice guidelines for low back pain: A case control cohort study of knowledge translation in a multi-site healthcare organization.

The benefits of clinical practice guideline (CPG) adoption for the management of patients with back pain are well documented. However, the gap between knowledge creation and implementation remains wide with few studies documenting the iterative process of comprehensive implementation in clinical settings. The objective of this study was to improve adherent physical therapy care according to CPG's for low back pain and describe the knowledge to action (K2A) process used in a rural healthcare organization. A prospective case control cohort design was used to evaluate physical therapy provider practice changes during an 18 month intervention. Four clinical sites were selected, two of which received multifaceted educational and process interventions tailored to feedback from ongoing K2A cycle outcomes. Overall program assessment included monthly charge code reports for adherence and a pre-post survey of confidence for guideline use. Pragmatic Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) criteria were used to complete the process evaluation. A significant difference (p< 0.001, mean difference 13.5, CI [8.5,18.5]) for charge code adherence favoured education site-1 over control site-2 after implementation. Adherence scores remained above target at both education sites 18 months after implementation. Survey differences were significant for confidence scores at education sites in use of the cognitive behavioural category, overall treatment category use and guideline communication. Process evaluation supported multifaceted interventions tailored to education sites with average cost measured by staff education time of 15.5h per therapist trained. This study extends the literature of guideline implementation by describing the unique cycles required for promoting provider behaviour change within a rural healthcare system. Adherence and confidence results suggest increased provider CPG use which was supported by the process evaluation. This study demonstrates the importance of multiple site comparisons, long-term reporting and standardized frameworks for assessment of real-world CPG implementation.

BLITZ-HF study: a nationwide initiative to assess and improve guidelines recommendations adherence in cardiology centers managing patients with acute and chronic heart failure

Abstract Background Physicians adherence to heart failure (HF) guidelines is generally sub-optimal with consequent negative prognostic implications. Strategies to improve adherence to guideline recommendations are strongly needed. Aims To assess and improve adherence of Italian cardiology sites to guidelines recommendations on performance indicators in patients with acute (AHF) and chronic heart failure (CHF). Methods BLITZ-HF was a prospective study based on a web based recording system used during two enrollment periods (phase 1 and 3), interspersed by face-to-face macro-regional benchmark analysis and educational meetings (phase 2). Both management (creatinine and echocardiographic evaluations or discharge follow-up planning) and treatment (according to ejection fraction categories, focusing on guidelines directed medical treatments - GDMTs) performance indicators were considered for patients in both settings. Results Overall, 7218 patients with acute and chronic HF were enrolled at 106 sites. During the enrollment phases, 3920 and 3298 patients were included respectively, 84% with CHF and 16% with AHF in phase 1, 74% with CHF and 26% with AHF in phase 3. In Figure 1 we report adherence to management and treatment indicators in the two enrollment phases. Among AHF patients improvement was obtained in two of seven indicators. A significant rise in echocardiographic evaluation was observed, while discharge schedule of a cardiology ambulatory evaluation within four weeks was overall poor (less than 50%) and did not improve in the 3 phase. Overall GDMTs prescription rate in HFrEF was good and we observed a nominal increase in betablockers prescription rate in Phase 3. Among CHF patients with HFpEF and HFmrEF we observed a performance increase in two of three indicators: creatinine end echocardiographic evaluations, while oral anticoagulation in atrial fibrillation remained stably high. Performance measures in CHF HFrEF patients improved in six of nine indicators although significantly only in two. Prescription rate of GDMTs was good already in phase 1 and a significant increase in ACE-I/ARB or ARNI prescription was reported, with a nominal increase in the use of one of these three drugs in combination with MRAs and a BB. Conclusions A structured multifaceted educational intervention can improve adherence to HF guidelines on several indicators in a context of an already elevated level of adherence to guideline recommendations. Extension of this approach to other non-cardiology health professional settings, in which patients with HF are generally managed, should be considered. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): The study was funded by Heart Care Foundation with a partial unrestricted support from Abbott, Daiichi Sankyo, Medtronic, Servier, Vifor.

Clinical and healthcare improvement through My Health Record usage and education in general practice (CHIME-GP): a study protocol for a cluster-randomised controlled trial

BackgroundThere is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system.MethodsThe trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention.DiscussionThe trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice.Trial registrationClinicalTrials.gov ACTRN12620000010998. Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry

Can multifaceted educational intervention improve clinical practice and patient outcomes regarding delirium in nursing homes?

We aimed to develop and evaluate a multifaceted and evidence-based delirium educational program for practitioners in nursing home settings. A pre- and posttest comparison group design was employed. The recruited practitioners included nurses and care workers from two nursing homes. The intervention group (n=51) received the developed delirium educational program for 3 weeks, whereas the control group (n=23) received a delirium handbook. We examined pre- and posttest differences in the scores for delirium knowledge and confidence in providing delirium care. We also examined the nurses' ability to clinically detect delirium in patients and delirium incidence for 8-week periods both before and after the intervention. There were significant improvements in the participants' aptitudes (delirium knowledge and confidence in providing delirium care) and clinical practice (ability to clinically detect delirium in the patients) only in the intervention group; however, there were no significant differences in patient outcomes (incidence of delirium) between either group. Additionally, it was observed that the nurses' improved understanding of distinct clinical features of delirium, such as acute change or fluctuation, was the key factor that directly affected the success of delirium screening. This study revealed that implementation of a multifaceted and evidence-based delirium educational program for practitioners in nursing home settings was effective in promoting the knowledge, confidence, and ability to detect delirium. The developed program can also be implemented in settings where most patients are older individuals, such as geriatric care units, or long-term care hospitals.

Description and Determinants of At-Risk Interactions for Human Health Between Children and Dogs in an Inuit Village

ABSTRACT While dogs can have a positive impact on physical and mental health, they also represent a public health risk in terms of bites and zoonotic diseases. In the specific context of Inuit villages, the role, care, and value of dogs are culturally different than in southern Canada. Furthermore, rabies is endemic to the region. Dogs are frequently kept outside, and the risk of bites and deadly attacks is higher than in southern Canada, particularly in children. Thus, reducing at-risk interactions between children and dogs through prevention programs requires a strong understanding of the unique dog–child relationship in this particular setting. This study used quantitative and qualitative research methods to examine the characteristics of interactions that put children at risk in Kuujjuaq, an Inuit village in Quebec, Canada. Data were collected using 40 observational walks, 34 semi-structured interviews, and 31 conversational interviews. Seven types of at-risk child–dog interactions were identified: showing affection to the dog, ignoring the dog, playing with the dog, running away from the dog, intervening during a dog fight, attacking the dog, and untying the dog. According to interviewees, the last four types of interaction put children’s health directly at risk. All interactions were directly observed, though rarely, except for the untying of dogs. The interview analysis identified several determinants for these at-risk interactions at the child, family, socio-situational, and macro levels. As some of these determinants are modifiable, these findings advocate for a multifaceted educational intervention that targets children, parents, dog owners, and the whole community, while respecting the particular context of Kuujjuaq. This study offers specific insights that could guide the development of a socio-culturally sensitive education program aimed at improving the relationship between children and dogs in Inuit villages and thereby reducing the incidence of dog bites.