Unwarranted Practice Variation Research Articles

Development of a Novel Evidence-Based Practice-Specific Competency for Doctor of Physical Therapy Students in Clinical Education: A Modified Delphi Approach.

Evidence-based practice (EBP) results in high-quality care and decreases unwarranted variation in practice. Few performance criteria related to EBP are included in physical therapy clinical education (CE) performance measures, despite EBP requirements in Doctor of Physical Therapy education. The purpose of this study was to develop EBP-specific competencies that may be used for Doctor of Physical Therapy students for use throughout CE. Thirteen subject matter experts (SME) participated in this study. Subject matter experts were asked to rank each core EBP competency, from a previously described framework, using a 3-point Likert scale, which included "Not Essential," "Essential," and "Not Sure." A consensus of 70% or greater for the "Essential" rating advanced the competency to the final Delphi round, whereas a consensus of 70% or greater for the "Not Essential" rating was required for competency elimination. Subject matter experts voted to either "Accept" or "Modify" the competencies that had reached the inclusion consensus threshold. All competencies that reached consensus for inclusion after all 3 rounds were included in the final EBP Domain of Competence. Consensus was achieved in round one for 38% (n = 26) of items. In round 2, a consensus was achieved for 20% (n = 8) of items. Of the items remaining after rounds 1 and 2, 6 overarching competencies were identified, and all remaining items served as descriptions and specifications in the final EBP Domain of Competence. The 6 competencies developed from this study constitute the EBP Domain of Competence and may be used throughout CE to assess students' EBP competency in clinical practice.

Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint.

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

Managing unwarranted variation in hospital care – findings from a regional audit in Norway

Background/AimThere has been increasing focus and research over the past decades on defining, identifying, visualizing and reducing unwarranted clinical variation in clinical practice. Both clinician-driven initiatives such as the US based “Choosing Wisely” campaign and the top-down driven “Evidence-based intervention programme (EBI)” launched by NHS UK to improve quality of care by reducing unnecessary interventions have shown marginal results. We present the findings from a mixed-methods audit performed to evaluate the compliance by senior hospital leaders of a new regional strategy to reduce unwarranted variation in outcomes and utilization rates.MethodsSeventy-five mid- to senior-division and department leaders from eight hospital trusts in South-Eastern Norway Regional Trust (HSO) were invited to participate in evaluating the response and compliance of the regional leadership strategy for reducing unwarranted variation in patient outcomes and service utilization rates.ResultsThe audit revealed that the aim of reducing unwanted variation was not clearly communicated by senior HSO management. There was varying use of data from the national quality registers and health atlases for quality improvement. One third of the clinical leaders reported a lack of scrutiny of their work and were insufficiently aware of the HSO’s top-management and the hospital’s Boards strategic expectations about the importance of reducing unwarranted variation in their hospital utilization.ConclusionsWe found that the strategic aim of reducing unwanted clinical variation was not clearly communicated by senior HSO management to hospital boards and senior management.The hospitals could benefit from a better understanding of causes of variation by strengthening their efforts to reduce unwarranted variation in utilization rates as a key element in improving health care quality and patient safety. The findings of the audit are relevant for other healthcare organizations trying to improve their quality and reduce unnecessary variation.

Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients

Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients

Variation in Rates of Post-Mastectomy Radiotherapy Among Women with Early Invasive Breast Cancer in England and Wales: A Population-Based Cohort Study

AimsThis study examined whether patterns of post-mastectomy radiotherapy (PMRT) among women with early invasive breast cancer (EIBC) varied within England and Wales and explored the role of different patient factors in explaining any variation. Materials and methodsThe study used national cancer data on women aged ≥50 years diagnosed with EIBC (stage I–IIIa) in England and Wales between January 2014 and December 2018 who had a mastectomy within 12 months of diagnosis. A multilevel mixed-effects logistic regression model was used to calculate risk-adjusted rates of PMRT for geographical regions and National Health Service acute care organisations. The study examined the variation in these rates within subgroups of women with different risks of recurrence (low: T1-2N0; intermediate: T3N0/T1-2N1; high: T1-2N2/T3N1-2) and investigated whether the variation was linked to patient case-mix within regions and organisations. ResultsAmong 26 228 women, use of PMRT increased with greater recurrence risk (low: 15.0%; intermediate: 59.4%; high: 85.1%). In all risk groups, use of PMRT was more common among women who had received chemotherapy and decreased among women aged ≥80 years. There was weak or no evidence of an association between use of PMRT and comorbidity or frailty, for each risk group. In women with an intermediate risk, unadjusted rates of PMRT varied substantially between geographical regions (range 40.3–77.3%), but varied less for the high-risk (range 77.1–91.6%) and low-risk groups (range 4.1–32.9%). Adjusting for patient case-mix reduced the variation in regional and organisational PMRT rates to a small degree. ConclusionsRates of PMRT are consistently high across England and Wales among women with high-risk EIBC, but variation exists across regions and organisations for women with intermediate-risk EIBC. Effort is required to reduce unwarranted variation in practice for intermediate-risk EIBC.

Practice variation in opioid prescribing for non-cancer pain in Dutch primary care: A retrospective database study.

Prescription opioid use has increased steadily in many Western countries over the past two decades, most notably in the US, Canada, and most European countries, including the Netherlands. Especially the increasing use of prescription opioids for chronic non-cancer pain has raised concerns. Most opioids in the Netherlands are prescribed in general practices. However, little is known about variation in opioid prescribing between general practices. To better understand this, we investigated practice variation in opioid prescribing for non-cancer pain between Dutch general practices. Data from 2017-2019 of approximately 10% of all Dutch general practices was used. Each year included approximately 1000000 patients distributed over approximately 380 practices. The primary outcome was the proportion of patients with chronic (>90 days) high-dose (≥90 oral morphine equivalents) opioid prescriptions. The secondary outcome was the proportion of patients with chronic (<90 oral morphine equivalents) opioid prescriptions. Practice variation was expressed as the ratio of the 95th/5th percentiles and the ratio of mean top 10/bottom 10. Funnel plots were used to identify outliers. Potential factors associated with unwarranted variation were investigated by comparing outliers on practice size, patient neighbourhood socioeconomic status, and urbanicity. Results were similar across all years. The magnitude of variation for chronic high-dose opioid prescriptions in 2019 was 7.51-fold (95%/5% ratio), and 15.1-fold (top 10/bottom 10 ratio). The percentage of outliers in the funnel plots varied between 13.8% and 21.7%. Practices with high chronic high-dose opioid prescription proportions were larger, and had more patients from lower income and densely populated areas. There might be unwarranted practice variation in chronic high-dose opioid prescriptions in primary care, pointing at possible inappropriate use of opioids. This appears to be related to socioeconomic status, urbanicity, and practice size. Further investigation of the factors driving practice variation can provide target points for quality improvement and reduce inappropriate care and unwarranted variation.

Regional Differences in Procedural Care of Hemorrhoid Management in Medicare Patients; Unwarranted Variation in Clinical Practice for a Medical-First Problem

IntroductionHemorrhoid disease is very common problem in the Medicare population. Prior work has shown significant variation in county-level practices of hemorrhoidectomy; however, regional variation of rubber band ligation (RBL) has yet to be assessed. This is important as many different practitioners from different specialties can perform this procedure repeatedly in an office-based setting. We aim to evaluate the variation of RBL and hemorrhoidectomy over a 7-y period. MethodsUsing Medicare part B claims data, we identified all beneficiaries >65 y seen for hemorrhoid disease between 2006 and 2013. Current Procedural Terminology (CPT) codes were used to identify all events for hemorrhoidectomy (46083, 46250, 46255, 46257, 46260, and 46261) or RBL (46221) by hospital referral region (HRR). We determined HRR-level rates of hemorrhoidectomy and RBL per 1000 beneficiaries adjusted for age, sex, and race. We calculated annual coefficients of variation (SD × 100/mean) for hemorrhoidectomy and RBL. Results1.2 to 1.3 million fee-for-service Medicare beneficiaries were seen annually for evaluation of hemorrhoid disease. Mean-adjusted annual rates for hemorrhoidectomy by HRRs varied from 4.34 to 63.03 per 1000 beneficiaries. Mean-adjusted rates of RBL by HRRs varied from 7.06 to 163 per 1000 beneficiaries. Annual procedural coefficients of variation over the study period were 41-48 (high) for hemorrhoidectomy and 69-74 (very high) for RBL. ConclusionsWhile continued high variation exists for hemorrhoidectomy, there is very high variation for RBL between HRRs in treating hemorrhoid disease among Medicare beneficiaries. There are substantial Medicare expenditures in this high-volume population that are likely unwarranted.

Temporal Trends and Variation in Bronchoscopy Use for Acute Respiratory Failure in the United States

National data on bronchoscopy for the evaluation of acute respiratory failure are lacking, and the limited available data suggest wide variation in use. How commonly is bronchoscopy performed among hospitalizations with acute respiratory failure? How has use changed over time and across hospitals? This was an observational cohort study of adult hospitalizations (2012-2018) treated with invasive mechanical ventilation (IMV) using the National Inpatient Sample, which represents 97%of all hospitalizations in the United States. We measured the proportion of hospitalizations treated with IMV who underwent bronchoscopy and assessed trends in bronchoscopy use over time. Multilevel linear regression models were used to quantify hospital-level variation, adjusting for differences in patient and hospital characteristics. We identified 6,101,070 IMV-treated hospitalizations (2012-2018), of whom 609,405 underwent bronchoscopy; among hospitalizations receiving bronchoscopy, mean age was 61 years, 41.8%were women, and in-hospital mortality was 30.8%. The percentage of IMV-treated hospitalizations receiving bronchoscopy increased from 9.5%(95%CI, 9.1%-9.9%) in 2012 to 10.8%(95%CI, 10.4%-11.2%) in 2018 (P< .001 for difference). In 2018, bronchoscopy use varied from 0%to 57.1%among 1,787 hospitals, and in multilevel models adjusted for patient and hospital characteristics, 16.0%of the variation was explained at the hospital level. The median OR was 2.13 (95%CI, 2.05-2.21), indicating 113%increased odds of receiving bronchoscopy if moving from a lower-use to a higher-use hospital. Bronchoscopy use among hospitalizations treated with IMV has increased over time. The large variation in use of bronchoscopy across hospitals suggests potentially unwarranted practice variation and need for further studies to clarify which patients benefit from bronchoscopy.

Quality and variation of care for chronic kidney disease in Swiss general practice: A retrospective database study.

Chronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013-2019. We defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs). We observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2-3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2). This study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013–2017)

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref = 4.67 (LEOPEN) and SCV/SCVref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013–2017)

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref= 4.67 (LEOPEN) and SCV/SCVref= 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Unwarranted variation in radiation therapy fractionation.

The adoption of hypofractionation across multiple tumour sites has been slow despite robust evidence. There is considerable unwarranted variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician preference, lack of technology and differing financial incentives. Unwarranted variation in the use of hypofractionation has a tremendous effect on cost to both patients and the healthcare system. This places an unnecessary burden on patients and poorly utilises scarce healthcare resources. A collaborative effort from clinicians, patients, healthcare providers and policymakers is needed to reduce unwarranted variation in practice. This will improve quality of care both for patients and at broader healthcare system level.

Competency-Based Education and Practice in Physical Therapy: It's Time to Act!

Competency-based education (CBE) is a concept, a philosophy, and an approach to educational design where learner progression occurs when competency is demonstrated. It assumes a set of standard defined performance outcomes for any level of professional practice-students, residents, or practicing physical therapists. Those outcomes are based on the health needs of society and guide the curricular design, implementation, and evaluation of health professions education programs. Lack of a CBE framework-with no required demonstration of competence throughout one's career-has the potential to lead to variation in physical therapists' skills and to unwarranted variation in practice, potentially hindering delivery of the highest quality of patient care. CBE requires a framework that includes a commonly understood language; standardized, defined performance outcomes at various stages of learner development; and a process to assess whether competence has been demonstrated. The purpose of this perspective article is to (1) highlight the need for a shared language, (2) provide an overview of CBE and the impetus for the change, (3) propose a shift toward CBE in physical therapy, and (4) discuss the need for the profession to adopt a mindset requiring purposeful practice across one's career to safely and most efficiently practice in a given area. Utilizing a CBE philosophy throughout one's career should ensure high-quality and safe patient care to all-patient care that can adapt to the changing scope of physical therapist practice as well as the health care needs of society. The physical therapy profession is at a point at which we must step up the transition to a competency-based system of physical therapist education.

Getting it Right First Time (Part 2)

Launched in 2015, the Getting it Right First Time (GIRFT) programme is a change agent for quality improvement in the NHS. In September 2021 the GIRFT neurology report was published, which outlines a whole pathway approach for the management of unwarranted variation in neurology practice and the actions needed to improve patient outcomes. In part 1, published in BJNN volume 17 issue 6, Sue Thomas explored what GIRFT says about the organisation of neurology services and its recommendations for service delivery. Part 2 explores parallel services, commissioning and future directions.

To what extent do home care nurses feel free to assess the care that is needed for their patients? A nationwide survey in the Netherlands.

Background and AimsPatients receiving nursing care at home require a needs assessment. There are indications that practice variation exists in needs assessments performed by Dutch home care nurses. One possible cause is that nurses are differentially influenced by others when performing needs assessments. Instruments recommending what is appropriate care have the potential to protect nurses against unwarranted influences. In the Netherlands, a framework exists including general norms about performing needs assessments. We aimed to achieve insight into whether nurses, who have heard of the framework, feel more free to assess the care that is needed for their patients, and whether other actors play a role in performing needs assessments.MethodsAn online questionnaire was sent to members of the Dutch Nursing Staff Panel (response 47%; n = 302) in November 2019. Only nurses who perform needs assessments were included in the analyses (n = 141). χ2‐tests were used to assess the relationships between the variables of having heard of the framework, feeling free to assess the care that is needed, and the influences of others.ResultsWe found no relationships between having heard of the framework and feeling free to assess the care that is needed for patients or reporting influence of others. However, home care nurses who state that they are not influenced by others, feel more free to assess the care that is needed for their patients. In contrast, those who state that they are influenced by informal caregivers, or health care insurers, feel less free to assess the care that is needed.ConclusionIt appears that the framework for performing needs assessments does not, in its current form, protect against influences of others. Further research is recommended to examine what kind of instruments nurses need to perform unambiguous and good needs assessments and, as such, reduce unwarranted practice variation.

Temporal Trends and Hospital Variation in Time-to-Antibiotics Among Veterans Hospitalized With Sepsis

It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021. Time from presentation to antibiotic administration. The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models. A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P < .001). In multilevel models adjusted for patient characteristics, median time-to-antibiotics declined by 9.0 (95% CI, 8.8-9.2) minutes per calendar year. Temporal trends in time-to-antibiotics were similar across patient subgroups, but hospitals with faster baseline time-to-antibiotics had less change over time, with hospitals in the slowest tertile decreasing time-to-antibiotics by 16.6 minutes (23.1%) per year, while hospitals in the fastest tertile decreased time-to-antibiotics by 7.2 minutes (13.1%) per year. In the most recent years (2017-2018), median time-to-antibiotics ranged from 3.1 to 6.7 hours across hospitals (after adjustment for patient characteristics), 6.8% of variation in time-to-antibiotics was explained at the hospital level, and odds of receiving antibiotics within 3 hours increased by 65% (95% CI, 56%-77%) for the median patient if moving to a hospital with faster time-to-antibiotics. This cohort study across nationwide VA hospitals found that time-to-antibiotics for sepsis has declined over time. However, there remains significant variability in time-to-antibiotics not explained by patient characteristics, suggesting potential unwarranted practice variation in sepsis treatment. Efforts to further accelerate time-to-antibiotics must be weighed against risks of overtreatment.

Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations.

BackgroundSystems to detect and minimise unwarranted variation in clinician practice are crucial to ensure increasingly multidisciplinary healthcare workforces are supported to practise to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care.AimTo evaluate the benefits and limitations of a continuous, risk-based, consultation peer-review system used for 10 years by an out-of-hours general practice service in Bristol, UK.Design and settingA qualitative study in South West England.MethodSemi-structured interviews with intervention users (clinicians, peer reviewers, and clinical management), analysed by inductive thematic analysis and integrated into a programme theory.ResultsTwenty clinicians were interviewed between September 2018 and January 2019. Interviewees indicated that the intervention supported clinician learning through improved peer feedback, highlighting learning needs and validating practice. It was compared favourably with existing structures of ensuring clinician competence, supporting standardisation of supervision, clinical governance, and learning culture. These benefits were potentially limited by intervention factors such as differential feedback quality between clinician groups, the efficiency of methods to identify learning needs, and limitations of assessments based on written clinical notes. Contextual factors such as clinician experience, motivation, and organisational learning culture influenced the perception of the intervention as a support or a stressor.ConclusionThe findings demonstrate the potential of continuous, risk-based, consultation peer review to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practise to their full potential. The programme theory provides a theoretical basis to maximise the benefits and accommodate the potential limitations of this methodology

To what extent have key recommendations from the Getting It Right First Time programme for urology in England been implemented?

Objectives: The Getting It Right First Time programme was set up to reduce unwarranted variation in healthcare practice and outcomes in England. The aim of this study was to investigate early changes in practice in urology based on the recommendations made. Subjects and methods: Data were extracted from the Hospital Episodes Statistics database from January 2014 to December 2019. The dates of visits by members of the Getting It Right First Time team were taken as the intervention point. Interrupted time series analysis was used to identify trends pre and post intervention. Results: Following the Getting It Right First Time visits, there was evidence of a significant increase in the proportion of patients seen as day cases for transurethral resection of bladder tumour and decreased use of stents and increased use of ureteroscopy or extracorporeal shock wave lithotripsy on first presentation with ureteric stones. However, there was no significant change in waiting times for surgery to treat patients who had an emergency presentation with urinary retention. Conclusions: There is evidence that the recommendations made are already having an impact on clinical practice. The reasons why some recommendations appear to be harder to implement requires further investigation. Level of evidence: 2b

Developing critical thinking skills for delivering optimal care

Healthcare systems across the world are challenged with problems of misdiagnosis, non-beneficial care, unwarranted practice variation and inefficient or unsafe practice. In countering these shortcomings, clinicians must be able to think critically, interpret and assimilate new knowledge, deal with uncertainty and change behaviour in response to compelling new evidence. Three critical thinking skills underpin effective care: clinical reasoning, evidence-informed decision-making and systems thinking. It is important to define these skills explicitly, explain their rationales, describe methods of instruction and provide examples of optimal application. Educational methods for developing and refining these skills must be embedded within all levels of clinician training and continuing professional development.

A Knowledge Translation Framework for Optimizing Physical Therapy in Patients With Heart Failure.

The American Physical Therapy Association has supported the development of clinical practice guidelines to promote and support evidence-based practice and reduce unwarranted practice variation. Essential to the success of this effort is the generation of knowledge translation, a concept that emphasizes the translation of global knowledge to an application that can be effectively integrated into clinical practice. The Physical Therapy Clinical Practice Guideline for the Management of Individuals with Heart Failure published in the Physical Therapy Journal in January 2020 provides a broad base of knowledge related to evidence-based treatment interventions for patients with heart failure. However, the application and integration of this knowledge in clinical practice need further elucidation. Therefore, this perspective paper aims to serve as a complementary knowledge translation resource to the recently published practice guideline to maximize the utilization of contemporary evidence in clinical practice. This resource provides the physical therapist with practical guidance in the management of patients with heart failure by placing research findings in the context of other knowledge and practice norms that can be applied at the point of care and across the continuum of care. We propose a novel ABCDE (assessment, behavior modification, cardiorespiratory fitness, dosage, and education) practical framework. This clinical paradigm is grounded in ongoing physical therapist assessment throughout the episode of care, along with behavior modification, assessment of cardiorespiratory fitness, appropriate selection and dosing of interventions, and patient education. Examples highlighting the use of this model in patients with heart failure across the continuum of care are provided for application in clinical care.