System-based Intervention Research Articles

Testing a family system-based intervention (ENTREN-F Programme) for a paediatric obesity sample by a randomized controlled trial

This study evaluated the effectiveness of ‘ENTREN-F’ –a multi-component, family system-based intervention-for managing paediatric obesity at National Health Primary Care. A 3-arm, parallel-design, single-blinded randomized controlled trial (RCT), 165 families were randomized: Arm 1) ENTREN-F(n = 62) is a 12-week cognitive-behavioural intervention (CBT) family system-based programme, addressing lifestyle changes, children's emotional and social development and the family system, Arm 2) ‘ENTREN’ (n = 52) is a CBT family-based programme for children and parents, not addressing the family system, and Arm 3) Control group (CG) (n = 51) covers individual behavioural monitoring. All children were clinical interviewed to assess a diagnosis. Their effectiveness was assessed against six-month changes in children's body mass index (BMI) z-score, children's psychological well-being, levels of expressed maternal emotion, depression symptoms, parental feeding practices, levels of physical activity and sedentary lifestyles. The maintenance of the changes was evaluated for two years. High-attendance rates for ENTREN-F (72.6% vs. 66% vs. 33%, respectively) indicated its greater acceptance. After programme completion, the BMI z-score reduced by .5 points in almost 50% ENTREN-F (n = 22/45), 21.9% ENTREN (n = 7/32) and 11.8% (n = 2/17) CG participants. There were no significant differences between the three trial arms for anthropometric, psychological, or family-related measures. At the two-year follow-up, both ENTREN-F and ENTREN showed similar long-term effectiveness without between-group differences, and weight trajectories were favourable. ENTREN-F appears effective for childhood obesity management; however, the COVID-19 pandemic limited the sample size. Also, the tendency towards multiple differences in child and family outcomes could not be statistically shown. It also provides further evidence of the role of psychological and family-related factors that may underlie the origin and maintenance of weight gain.

The newborn individualised developmental care and assessment program: A model of care for infants and families in hospital settings.

The Newborn Individualised Developmental Care and Assessment Program (NIDCAP) is an intervention and education programme that uses developmental observation for multidisciplinary healthcare professionals (HCP) caring for high-risk infants and families. Infants prosper with the ongoing co-regulation process of infant and family that is influenced by the physical and social environment. The Template for Intervention Description and Replication (TIDieR) Guidelines were applied to the NIDCAP intervention. The estimation of the individual infant's current goals is described from direct observation of behaviour in the context of ongoing care delivery. The infant's behaviour guides all caregivers to articulate current strengths and functioning for the development of individualised plans of care and support. The NIDCAP Nursery Program supports the full integration of NIDCAP into the healthcare system. NIDCAP is a system-based, process-oriented, attuned and responsive intervention for individualised developmental care for infants and families. Evidence shows NIDCAP significantly improves medical outcomes, with less time on the ventilator, improved weight gain, decreased length of stay, improved developmental outcomes and enhanced infant and family relationships. Evidence suggests that NIDCAP as an intervention improves parental competence, decreases stress for HCP teams and improves HCP satisfaction. NIDCAP improves outcomes for infants and families requiring hospital care.

MOVIN PAST OBSTACLES: BUILDING A CULTURE OF MOBILITY

Abstract Older adults are at risk for losing their ability to ambulate independently during hospitalization. The “MOVIN” (Mobilizing Older adult patients Via a systems-based Intervention) Study is a cluster-randomized control trial aimed to implement a nursing-led mobility model and monitor the change in nurse behaviors and unit culture before, during and after the 14-week intervention period. The model includes psychomotor training, mobility resources (equipment and ambulation aide), communication tools, ambulation pathways, and support for developing a “culture of mobility” led by nurses. It was launched on two inpatient nursing units at large urban Magnet quaternary medical center in Wisconsin in July 2021 (Unit 1) and March 2022 (Unit 2). Electronic reports based on documentation were generated to monitor patient ambulation and distances for feedback and celebration. The researchers and unit teams met often to implement and ensure intervention integrity despite increasing care demands and staffing shortages. Unit leaders navigated pandemic-induced obstacles including turnover, shortages, and high patient volumes by refining staff training, streamlining communication, promoting in-room walking, and finding creative ways to celebrate and build a culture within the COVID-19 restrictions. Unit 1 ambulated 75% of patients (20% increase) with distances averaging 47 miles/month (540% increase). Unit 2, with less ambulatory patients, ambulated 73% of patients (18% increase) with distances averaging 23.4 miles/month (680% increase). MOVIN is a promising system-based intervention that supports culture change and promotes nurse-led patient ambulation. Units were able to increase and sustain the quantity and quality of patient walking despite the obstacles imposed by the pandemic.

1033-P: Improving T2D Collaboration and Patient Communication at the Primary Care Level—Findings from Team-Designed Quality Improvement Education Initiative

Background: A system-based Quality Improvement Education intervention (QIEi) was developed to improve disease management for T2D patients with/at-risk of CVD/CKD who may benefit from SGLT-2i/GLP-1RA. The QIEi aimed to improve competencies of PCPs, team collaboration and patient communications. Methods: The QIEi was deployed to PCPs at 2 sites from a USA integrated delivery system. Practice Assessments (PrA) and a pre-intervention EHR data review confirmed the gaps and guided QI team discussions. Team leaders designed webinars on best practices (recorded for later view), and the groups discussed cases, designed process improvements and communication strategies (EHR Smart phrases, clinical reinforcement materials explaining treatments, and enhanced After Visit Summary). Evaluation included PrA (pre=140; post=55), EHR data, smart phrase usage, and qualitative interviews (n=10). Results: PCPs’ comfort discussing treatment with patients increased (Table 1). Interviewees reported an increase in patient interface, confidence educating patients and team engagement. The QIEi led to system-based changes and sustained clinical reinforcement material adoption. Conclusion: A team based QIEi can result in effective design, pilot/adoption of patient materials/EHR tools, supporting patient conversations and fostering informed decisions. Disclosure V.Makin: Speaker's Bureau; Bayer Inc. G.Jacobs: None. B.Dennis frampton: None. K.M.Pantalone: Consultant; AstraZeneca, Bayer Inc., Corcept Therapeutics, Diasome, Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk, Sanofi, Research Support; Bayer Inc., Merck & Co., Inc., Novo Nordisk, Twin Health, Speaker's Bureau; AstraZeneca, Corcept Therapeutics, Merck & Co., Inc., Novo Nordisk. S.Kawczak: None. S.Murray: None. P.Mcfadden: None. P.Rao: None. Funding Eli Lilly and Company; Merck & Co., Inc.

Effects of a feedback intervention on antibiotic prescription control in primary care institutions based on a Health Information System: a cluster randomized cross-over controlled trial

Overuse and misuse of antibiotics are major factors in the development of antibiotic resistance in primary care institutions of rural China. In this study, the effectiveness of a Health Information System-based, automatic, and confidential antibiotic feedback intervention was evaluated. A randomized, cross-over, cluster-controlled trial was conducted in primary care institutions. All institutions were randomly divided into two groups and given either a three-month intervention followed by a three-month period without any intervention or vice versa. The intervention consisted of three feedback measures: a real-time pop-up warning message of inappropriate antibiotic prescriptions on the prescribing physician's computer screen, a 10-day antibiotic prescription summary, and distribution of educational manuals. The primary outcome was the 10-day inappropriate antibiotic prescription rate. There were no significant differences in inappropriate antibiotic prescription rates (69.1% vs. 72.0%) between two groups at baseline (P=0.072). After three months (cross-over point), inappropriate antibiotic prescription rates decreased significantly faster in group A (12.3%, P < 0.001) compared to group B (4.4%, P < 0.001). At the end point, the inappropriate antibiotic prescription rates decreased in group B (15.1%, P < 0.001) while the rates increased in group A (7.2%, P < 0.001). The characteristics of physicians did not significantly affect the rate of antibiotic or inappropriate antibiotic prescription rates. A Health Information System-based, real-time pop-up warnings, a 10-day prescription summary, and the distribution of educational manuals, can effectively reduce the rates of antibiotic and inappropriate antibiotic prescriptions.

Formative Development of ClockWork for the Postpartum Period: A Theory-Based Intervention to Harness the Circadian Timing System to Address Cardiometabolic Health-Related Behaviors

Individuals with body mass index (BMI) ≥ 25 kg/m2 before pregnancy have greater difficulty losing the weight gained during pregnancy, and this postpartum weight retention predicts higher risk for cardiometabolic disease. The postpartum period involves substantial disruptions in circadian rhythms, including rhythms related to eating, physical activity, sleep, and light/dark exposure, each of which are linked to obesity and cardiometabolic disease in non-pregnant adult humans and animals. We posit that a multi-component, circadian timing system-based behavioral intervention that uses digital tools-ClockWork-will be feasible and acceptable to postpartum individuals and help promote weight- and cardiometabolic health-related behaviors. We provide data from stakeholder interviews with postpartum individuals (pre-pregnancy BMI ≥ 25; n = 7), which were conducted to obtain feedback on and improve the relevance and utility of digital self-monitoring tools for health behaviors and weight during the postpartum period. Participants perceived the ClockWork intervention and digital monitoring app to be helpful for management of postpartum weight-related health behaviors. They provided specific recommendations for increasing the feasibility intervention goals and improving app features for monitoring behaviors. Personalized, easily accessible interventions are needed to promote gestational weight loss after delivery; addressing circadian behaviors is an essential component of such interventions. Future studies will evaluate the efficacy of the ClockWork intervention and associated digital tools for improving cardiometabolic health-related behaviors linked to the circadian timing system during the postpartum period.

Adherence level to the World health Organization surgical safety checklist and associated factors in operating rooms in a county teaching and referral hospital in South-Western Kenya

IntroductionWorld Health Organization (WHO) introduced the Surgical Safety Checklist (SSC) in 2008 to assure safety in Operating Rooms (ORs). Globally, adherence level varies with developing countries having the lowest levels compared to their developed counterparts. ObjectivesWe aimed to assess the level of adherence and identify factors that influence adherence to the WHO SSC in a county teaching and referral hospital in South Western Kenya. MethodsThe study preferred a mixed method cross-sectional design. WHO SSC adherence level was assessed by conducting a retrospective review of 424 surgical files that were randomly selected. OR staff (40) were targeted using census method and 31of them were interviewed using structured interviews to determine qualitative data on staff and institutional factors that influenced adherence practices to the WHO SSC. Quantitative data was analysed using Statistical Package for Social Sciences (SPSS). Both descriptive and analytical statistics were generated with statistical significance set at p=<0.05. Content analysis was adopted for qualitative data. Study FindingsWHO SSC was present in 100 % of the post-surgical files. Filling of the WHO SSC was attempted in 7.1 % of the surgeries done. Better adherence was noted in elective surgeries (78 %) compared to emergency (22%) ones. There was a varying adherence level per the type of surgeries with adult general surgeries posting better adherence (40 %) and orthopaedic surgeries were least adherent at 4 %. A decreasing trend in adherence level was noted subsequently through the three moments of surgery (‘sign in’ (5.7 %); ‘Time out’ (1.8 %); and ‘Sign out’ (0.7 %)). The average adherence level was established to be 2.7 %. Key staff factors that influenced adherence practices included; years of experience (p = 0.004), attitude (p = 0.014) and perception(p = 0.009). Additionally, institutional factors were; lack of essential consumables and drugs (77.4 %), lack of refresher trainings (54.5 %), understaffing (48.4 %) and lack of management support (45.2 %). ConclusionThe level of adherence to the WHO SSC was critically low. The aforementioned staff and institutional factors influenced the level of adherence. The study recommends a structured health system-based quality improvement intervention to improve the outcome (adherence) by addressing the root causes (Staff and institutional) to promote patient safety in OR.

Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study.

BackgroundMental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making.ObjectiveThe primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research.MethodsThis pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings.ResultsParticipants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex.ConclusionsRather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals.Trial RegistrationClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771International Registered Report Identifier (IRRID)DERR1-10.2196/37712

Bridge to Health/Puente a la Salud: a pilot randomized trial to address diabetes self-management and social needs among high-risk patients.

Social needs contribute to persistent diabetes disparities; thus, it is imperative to address social needs to optimize diabetes management. The purpose of this study was to determine determine the feasibility and acceptability of health system-based social care versus social care + behavioral intervention to address social needs and improve diabetes self-management among patients with type 2 diabetes. Black/African American, Hispanic/Latino, and low-income White patients with recent hemoglobin A1C (A1C) ≥ 8%, and ≥1 social need were recruited from an integrated health system. Patients were randomized to one-of-two 6-month interventions: (a) navigation to resources (NAV) facilitated by a Patient Navigator; or (b) NAV + evidence-based nine-session diabetes self-management support (DSMS) program facilitated by a community health worker (CHW). A1C was extracted from the electronic health record. We successfully recruited 110 eligible patients (54 NAV; 56 NAV + DSMS). During the trial, 78% NAV and 80% NAV + DSMS participants successfully connected to a navigator; 84% NAV + DSMS connected to a CHW. At 6-month follow-up, 33% of NAV and 34% of NAV + DSMS participants had an A1C < 8%. Mean reduction in A1C was clinically significant in NAV (-0.65%) and NAV + DSMS (-0.72%). By follow-up, 89% of NAV and 87% of NAV + DSMS were successfully connected to resources to address at least one need. Findings suggest that it is feasible to implement a health system-based social care intervention, separately or in combination, with a behavioral intervention to improve diabetes management among a high-risk, socially complex patient population. A larger, pragmatic trial is needed to test the comparative effectiveness of each approach on diabetes-related outcomes.

Reducing the Time to Blood Administration after Pediatric Injury: A Quality Improvement Initiative.

Introduction:Hemorrhage is the leading cause of preventable death in pediatric trauma patients. Timely blood administration is associated with improved outcomes in children and adults. This study aimed to identify delays to transfusion and improve the time to blood administration among injured children.Methods:A multidisciplinary team identified three activities associated with blood transfusion delays during the acute resuscitation of injured children. To address delays related to these activities, we relocated the storage of un-crossmatched blood to the emergency department (ED), created and disseminated an intravenous access algorithm, and established a nursing educator role for resuscitations. We performed comparative and regression analyses to identify the impact of these factors on the timeliness and likelihood of blood administration.Results:From January 2017 to June 2021, we treated 2159 injured children and adolescents in the resuscitation area, 54 (2.5%) of whom received blood products in the ED. After placing a blood storage refrigerator in the ED, we observed a centerline change that lowered the adjusted time-to-blood administration to 17 minutes (SD 11), reducing the time-to-blood administration by 11 minutes (β = −11.0, 95% CI = −22.0 to −0.9). The likelihood of blood administration was not changed after placement of the blood refrigerator. We observed no reduction in time following the implementation of the intravenous access algorithm or a nursing educator.Conclusions:Relocation of un-crossmatched blood storage to the ED decreased the time to blood transfusion. This system-based intervention should be considered a strategy for reducing delays in transfusion in time-critical settings.

Overall Survival From a Prospective Multi-Institutional Trial to Resolve Black-White Disparities in the Treatment of Early Stage Breast and Lung Cancer

Black patients with curable lung or breast cancer complete treatment less often than similar white patients contributing to worse survival. ACCURE was a system-based intervention trial shown to eliminate black-white disparities in treatment completion and improved completion for all. The current study investigates how the ACCURE intervention influenced survival disparity.We previously reported a prospective multi-institutional trial using a system-based intervention. Patients diagnosed with early-stage breast and lung cancer, aged 18 to 85 were eligible. Enrollment spanned from 2013 until 2015. Intervention components included: (1) a real time warning system derived from electronic health records, (2) feedback to clinical teams on cancer treatment according to race, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary study outcome was receipt of curative treatment. The current study compares 5-year survival according to race for eligible patients from the tumor registry during the study period with comparison to historical controls. The ACCURE study treatment for early-stage lung cancer included resection or stereotactic body radiotherapy (SBRT) and survivals are now reported separately.There were a total of 1,413 patients with stages 0, I & II lung and breast cancer diagnosed in 2013-2015 who were compared to 2,016 patients treated in 2007-2011. The table shows statistically significant improved survival for black and white breast cancer patients and white lung cancer patients over time, while the racial gap in survival was reduced for lung and breast cancer. The 5-year observed survivals for white (2150) versus black (644) breast patients increased from 91% vs. 89% (P = NS) to 94% for both. The 5-year observed survival for white (510) and black (125) lung narrowed from 43% and 37% (P = NS) to 56% and 54%. Subgroup analysis of lung cancer patients showed 5-year survival for surgery was 78.5% and 70.1% for white and black patients (P = NS) while survival for SBRT was 41.9% and 50% for white and black patients (P = NS).A systems-based intervention reduced racial gaps in treatment completion and improved care for all. This study suggests that equity in treatment may be associated with elimination of survival disparities during the ACCURE study. In the lung cancer sub-group, the higher survival of white lung cancer patients undergoing surgery and black patients undergoing SBRT may suggest some continued disparity in patient selection for lung resection. Further analysis of comorbid conditions and other important factors will shed light on the full survival impact of the intervention.

Effectiveness of system-based intervention in reducing incidence of type 2 diabetes and to improve the postnatal metabolic profiles in women with gestational diabetes mellitus: a randomized controlled study

Aim The objective of this study was to determine the effectiveness of system-based intervention in reducing the incidence of diabetes and to improve the postnatal metabolic profiles among women with gestational diabetes mellitus (GDM). Materials and methods For women in the intervention arm (n = 130), they received one session of individualized health education at 36 gestational weeks, a booklet of diabetes prevention, five-session of postpartum booster educational program which were conducted including 1 session of dietary and exercise counseling by dietician and physiotherapist at 6 weeks postpartum. For women in the control group (n = 168), standard treatment whereby they had received group therapy on diet and physical activity modification by dietician and staff nurses during the antenatal period. Results There were no significant differences in baseline characteristics between groups for most of the variables examined except for educational level which the control group had a higher education than the intervention group. The women assigned to system-based intervention have a significant difference to GDM women who were assigned to the control group for LDL and HDL but not in anthropometric measurements, blood pressure, glucose index, total cholesterol, and triglyceride. In addition, it was found that the incidence of Type 2 diabetes mellitus (T2DM) 2 years after delivery was 20% in the intervention arm compared to 17% in the control arm. Conclusion The system-based intervention was not statistically superior to the control intervention as there is no difference in terms of incidence of T2DM between the intervention and control group. We, therefore, suggested that more intensive interventions are needed to prevent GDM from developing into T2DM.

Costs of Interventions to Increase Vaccination Coverage Among Children in the United States: A Systematic Review.

The Community Preventive Services Task Force (CPSTF) has recommended several interventions that have been demonstrated to be effective at increasing vaccination coverage. Conduct a systematic review to examine the costs of interventions designed to increase vaccination coverage among children and adolescents in the United States. PubMed, EconLit, Embase, and Cochrane. Peer-reviewed articles from January 1, 2009 to August 31, 2019. Studies were identified with systematic searches of the literature, reviewed for inclusion criteria, abstracted for data on intervention, target population, costs, and risk of bias. Cost measures were reported as costs per child in the target population, costs per vaccinated child, incremental costs per vaccinated child, and costs per vaccine dose administered. Results were stratified by intervention type, vaccine, and age group. Thirty-seven studies were identified for full-text review. Across all interventions and age groups, the cost per child ranged from $0.10 to $537.38, and the incremental cost per vaccinated child ranged from $6.52 to $5,098.57. Provider assessment and feedback interventions had the lowest (median) cost per child ($0.17) and a healthcare system-based combined intervention with multiple components had the lowest (median) incremental cost per vaccinated child ($26.65). A community-based combined intervention with multiple components had the highest median cost per child ($537.38) and the highest median incremental cost per vaccinated child ($5,098.57). A small number of included intervention types and inconsistent cost definition. There is substantial variability in the costs of CPSTF-recommended interventions.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study

ObjectiveTo understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. MethodsWe implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. Results Fifty seven percent(117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. ConclusionWhile the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials.

ObjectiveTo analyze the effects of a standardized community health worker (CHW) intervention on hospitalization.Data Sources/Study SettingPooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016.Study DesignThe trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high‐poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices.Data Collection/Extraction MethodsThe primary outcome for this study was all‐cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3.Principal FindingsOver 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023).ConclusionsData from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system‐based social intervention.

Real-world implementation of serious illness care program (SICP) in cancer care.

e24112 Background: The Serious Illness Care Program (SICP) is a system-based intervention, including a conversation guide, which facilitates improved advance care planning (ACP) conversations between clinicians and seriously ill patients. A recent randomized control trial found the program reduced symptoms of depression and anxiety amongst oncology out-patients and improved process outcomes. We implemented the SICP in our center to determine if the effects of this program could be translated into the real world. Methods: Two outpatient oncology clinics implemented the SICP, each over a 16-week period. Patients were identified based on an answer of “no” to the question “would I be surprised if this patient died within the next year?”, or any patient with a diagnosis of metastatic pancreatic cancer, or symptom scores of &gt; 7 on more than three categories of the patient reported outcome dashboard. Physicians were trained on how to conduct the SICP conversation. One patient per week was identified and prepared to have the SICP conversation with the goal of at least 12 conversations in each 16-week period. Rates of SICP conversation documentation on our system’s “ACP and goals of care designation (GCD) Tracking Record” and GCD orders were recorded. Patient satisfaction after each conversation and physician comfort level over time were assessed. Results: 16 patients were identified (8 patients in each 16-week period). One patient was lost to follow-up. Of the remaining 15 patients who had the SICP conversation, 14 (93%) had documentation on the Tracking Record and 8 (53%) had a GCD order. This was a major improvement over baseline rates of documentation (e.g. &lt; 1 % Tracking Record use and 16% GCD for patients with GI cancers). 14 patients completed satisfaction surveys, of which 12 (86%) felt “completely” or “quite a bit” more heard or understood. Physician comfort level increased from 3.6 to 4.8 and from 4.8 to 5 out of 5, respectively over each 16-week period. Conclusions: SICP implementation resulted in high rates of documentation of goals and preferences. Patients felt heard and understood by their healthcare team, and comfort in these conversations improved over time for physicians. The goal number of conversations was not met, but otherwise the SICP was feasible to implement in the real world. Further study is required to identify the appropriate triggers and barriers to routine SICP conversations.

Improvement in adherence to antibiotic duration of therapy recommendations for uncomplicated cystitis: a quasi-experimental study.

Acute uncomplicated cystitis is one of the most common diagnoses for which antibiotic treatment is prescribed in the outpatient setting. Despite the availability of national guidelines, there remains a wide pattern in prescriber choices for therapy. Recent data portray a picture of consistently longer durations than recommended prescribed in outpatient settings. The objective was to evaluate the effect of a system-based intervention on adherence to guideline-recommended durations of therapy for uncomplicated cystitis in the outpatient setting. This quasi-experimental study included women aged 18-64 years who were seen at five family medicine clinics at an academic medical centre and were prescribed targeted antibiotics for uncomplicated cystitis (nitrofurantoin monohydrate/macrocrystals 100 mg, trimethoprim-sulfamethoxazole 160/800 mg or ciprofloxacin 250 mg). The intervention involved revising or adding pre-filled, but modifiable, default prescribing instructions in the electronic health record (EHR) for the targeted antibiotics. We evaluated adherence to guideline-recommended duration of therapy as well as days of therapy (DOT) before and after the intervention. A total of 787 pre-intervention and 862 post-intervention cases were included. Adherence to recommended duration of therapy increased from 29.4% to 76.3% (P < 0.01). The average DOT decreased by 23% from 6.6 to 5.1 (P < 0.01). A stewardship intervention consisting of revising/adding default prescribing instructions to targeted antimicrobials in an EHR was associated with increased adherence to recommended durations of therapy for uncomplicated cystitis and reduction of unnecessary antibiotic exposure. More studies are needed to confirm effectiveness across multiple medical record platforms.

Case Study: More Patient Safety by Design - System-based Approaches for Hospitals.

Since the publication of the report "To Err Is Human: Building a Safer Health System" by the US Institute of Medicine in 2000, much has changed with regard to patient safety. Many of the more recent initiatives to improve patient safety target the behavior of health care staff (e.g., training, double-checking procedures, and standard operating procedures). System-based interventions have so far received less attention, even though they produce more substantial improvements, being less dependent on individuals' behavior. One type of system-based intervention that can benefit patient safety involves improvements to hospital design. Given that people's working environments affect their behavior, good design at a systemic level not only enables staff to work more efficiently; it can also prevent errors and mishaps, which can have serious consequences for patients. While an increasing number of studies have demonstrated the effect of hospital design on patient safety, this knowledge is not easily accessible to clinicians, practitioners, risk managers, and other decision-makers, such as designers and architects of health care facilities. This is why the Swiss Patient Safety Foundation launched its project, "More Patient Safety by Design: Systemic Approaches for Hospitals," which is presented in this chapter.

A Prospective Multi-Institutional Trial to Resolve Black-White Disparities in the Treatment of Early Stage Lung Cancer

Non-small cell lung cancer is fatal when left untreated but early stage disease can be cured by surgery or stereotactic radiation. Black patients, however, receive curative treatment less than Whites. We performed a prospective multiinstitutional quality improvement trial at 5 cancer centers using a system-based intervention. Patients diagnosed with early stage lung cancer, aged 18 to 85 were eligible. Enrollment spanned April 2013 until December 2016. Intervention components included: (1) a real time warning system derived from electronic health records, (2) feedback to clinical teams on cancer treatment according to race, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary outcome was receipt of curative surgery or stereotactic radiation. There were 2841 early stage lung cancer patients in the retrospective (16% Black) group and 360 in the intervention (32% Black). For the retrospective baseline, crude treatment rates were 78% for White patients vs. 69% for Blacks (p < 0.001); this difference was confirmed by a model adjusted for age, cancer center site, cancer stage, gender, comorbid illness, and income – odds ratio (OR) 0.66 for Blacks (95% CI 0.51 – 0.85, p = 0.001). Within the intervention cohort the crude rate was 96.5% and 95% for Black and White patients, respectively (p = 0.56). The OR for the adjusted analysis was 2.1 (95% CI 0.41 – 10.4, p = 0.39) for Black vs. White patients. Between group comparisons confirmed treatment parity for the intervention. The table shows between group comparisons among patients with stage I or II non-small cell lung cancer using race-group combinations for a model comprised of white retrospective controls and the white and black study intervention group. A system-based intervention tested in 5 cancer centers reduced racial gaps and improved care for all. Greater improvement in treatment completion and reduction in racial disparity was seen in stereotactic radiation. Further study of these system interventions and wider implementation is warranted in a shift from reporting to resolving health inequity.Abstract 203; Table 1Treatment OutcomeComparison Patient GroupAdjusted Odds Ratio (95% CI)p-valueSurgical Treatment for CureBlack Intervention1.2 (0.73, 1.3)0.5Surgical Treatment for CureWhite Intervention1.6 (1.1, 2.9)0.008Surgery or Stereotactic Radiation for CureBlack Intervention11.9 (2.9, 49)0.001Surgery or Stereotactic Radiation for CureWhite Intervention5.8 (3.0, 11)<0.001 Open table in a new tab

The new challenge for improving psychosocial cancer care: shifting to a system-based approach.

There is a need to improve the psychosocial well-being of cancer patients. To date, intervention research has primarily focussed on improving psychosocial well-being through targeting singular aspects of care at the individual patient level. Sustainable, high-quality psychosocial care should address the issues faced by people diagnosed with cancer throughout the care pathway using a system-based approach. To examine the number of intervention trials attempting to improve psychosocial cancer care that have implemented a system-based approach. Five journals were selected and relevant studies across all years were extracted. Four criteria, argued to be essential characteristics of system-based change, were assessed: (1) establishing a culture change within the healthcare system/organisation, through designated leaders who endorse organisational goals; (2) adopting a multidisciplinary approach to change; (3) mapping the system and identifying points of leverage; and (4) measuring the impact of change and adapting establish feedback loops. The search strategy returned 1174 citations, of which five met the inclusion criteria. Of the intervention studies identified, three met none of the four defined criteria for a systems-based intervention, one study met criterion 2 only, and one study met all four criteria, however, was not a rigorous study design. This review of published psychosocial intervention trials in top-ranking psychosocial cancer care journals only found one study that met our criteria for evaluating system-based change. This is likely to be a consequence of the significant pragmatic and political barriers to conducting system-based intervention research.