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SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals): a protocol for a population-wide cohort study of outcomes of hospital care

Por: Ranasinghe · I. · Hossain · S. · Ali · A. · Horton · D. · Adams · R. J. · Aliprandi-Costa · B. · Bertilone · C. · Carneiro · G. · Gallagher · M. · Guthridge · S. · Kaambwa · B. · Kotwal · S. · O'Callaghan · G. · Scott · I. A. · Visvanathan · R. · Woodman · R. J.
Introduction

Despite global concerns about the safety and quality of health care, population-wide studies of hospital outcomes are uncommon. The SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals) study seeks to estimate the incidence of serious adverse events, mortality, unplanned rehospitalisations and direct costs following hospital encounters using nationwide data, and to assess the variation and trends in these outcomes.

Methods and analysis

SAFER Hospitals is a cohort study with retrospective and prospective components. The retrospective component uses data from 2012 to 2018 on all hospitalised patients age ≥18 years included in each State and Territories’ Admitted Patient Collections. These routinely collected datasets record every hospital encounter from all public and most private hospitals using a standardised set of variables including patient demographics, primary and secondary diagnoses, procedures and patient status at discharge. The study outcomes are deaths, adverse events, readmissions and emergency care visits. Hospitalisation data will be linked to subsequent hospitalisations and each region’s Emergency Department Data Collections and Death Registries to assess readmissions, emergency care encounters and deaths after discharge. Direct hospital costs associated with adverse outcomes will be estimated using data from the National Cost Data Collection. Variation in these outcomes among hospitals will be assessed adjusting for differences in hospitals’ case-mix. The prospective component of the study will evaluate the temporal change in outcomes every 4 years from 2019 until 2030.

Ethics and dissemination

Human Research Ethics Committees of the respective Australian states and territories provided ethical approval to conduct this study. A waiver of informed consent was granted for the use of de-identified patient data. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals.

Identifying optimal frameworks to implement or evaluate digital health interventions: a scoping review protocol

Por: Soobiah · C. · Cooper · M. · Kishimoto · V. · Bhatia · R. S. · Scott · T. · Maloney · S. · Larsen · D. · Wijeysundera · H. C. · Zelmer · J. · Gray · C. S. · Desveaux · L.
Introduction

Digital health interventions (DHIs) are defined as health services delivered electronically through formal or informal care. DHIs can range from electronic medical records used by providers to mobile health apps used by consumers. DHIs involve complex interactions between user, technology and the healthcare team, posing challenges for implementation and evaluation. Theoretical or interpretive frameworks are crucial in providing researchers guidance and clarity on implementation or evaluation approaches; however, there is a lack of standardisation on which frameworks to use in which contexts. Our goal is to conduct a scoping review to identify frameworks to guide the implementation or evaluation of DHIs.

Methods and analysis

A scoping review will be conducted using methods outlined by the Joanna Briggs Institute reviewers’ manual and will conform to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Studies will be included if they report on frameworks (ie, theoretical, interpretive, developmental) that are used to guide either implementation or evaluation of DHIs. Electronic databases, including MEDLINE, EMBASE, CINAHL and PsychINFO will be searched in addition to grey literature and reference lists of included studies. Citations and full text articles will be screened independently in Covidence after a reliability check among reviewers. We will use qualitative description to summarise findings and focus on how research objectives and type of DHIs are aligned with the frameworks used.

Ethics and dissemination

We engaged an advisory panel of digital health knowledge users to provide input at strategic stages of the scoping review to enhance the relevance of findings and inform dissemination activities. Specifically, they will provide feedback on the eligibility criteria, data abstraction elements, interpretation of findings and assist in developing key messages for dissemination. This study does not require ethical review. Findings from review will support decision making when selecting appropriate frameworks to guide the implementation or evaluation of DHIs.

Implementing a pharmacogenetic-driven algorithm to guide dual antiplatelet therapy (DAPT) in Caribbean Hispanics: protocol for a non-randomised clinical trial

Por: Hernandez-Suarez · D. F. · Melin · K. · Marin-Maldonado · F. · Nunez · H. J. · Gonzalez · A. F. · Gonzalez-Sepulveda · L. · Rivas-Tumanyan · S. · Naik · H. · Ruano · G. · Scott · S. A. · Duconge · J.
Introduction

Minority populations in the USA are disproportionately affected by cardiovascular conditions. Reduced responsiveness to clopidogrel among carriers of CYP2C19 variants has been reported in patients with either coronary artery disease (CAD) or acute coronary syndrome (ACS) after the percutaneous coronary intervention (PCI). Previous studies have evaluated CYP2C19 genotyping-guided antiplatelet therapy in selected populations; however, this has yet to be tested among Hispanics. Given the paucity of clinical research on CYP2C19 and antiplatelet clinical outcomes in Hispanics, our study will test the safety and efficacy of a genetic-driven treatment algorithm to guide dual antiplatelet therapy (DAPT) in Caribbean Hispanics.

Methods and analysis

This is a multicentre, prospective, non-randomised clinical trial that proposes an assessment of pharmacogenomic-guided DAPT in post-PCI Caribbean Hispanic patients with ACS or CAD. We will recruit 250 patients to be compared with a matched non-concurrent cohort of 250 clopidogrel-treated patients (standard-of-care). Major adverse cardiovascular events (MACEs) such as all-cause death, myocardial infarction (MI), stroke, coronary revascularisation, stent thrombosis and bleedings over 6 months will be the study endpoints. Among the recruited, high-risk patients will be escalated to ticagrelor and low-risk patients will remain on clopidogrel. The primary objective is to determine whether genetic-guided therapy is superior to standard of care. The secondary objective will determine if clopidogrel treatment in low-risk patients is not associated with a higher rate of MACEs compared with escalated antiplatelet therapy in high-risk patients. Patients will be enrolled up to the group’s completion.

Ethics and dissemination

Approval was obtained from the Institutional Review Board of the University of Puerto Rico Medical Sciences Campus (protocol # A4070417). The study will be carried out in compliance with the Declaration of Helsinki and International Conference on Harmonization Good Clinical Practice Guidelines. Findings will be published in a peer-reviewed journal and controlled access to experimental data will be available.

Trial registration number

NCT03419325; Pre-results.

Intra-session and inter-rater reliability of spatial frequency analysis methods in skeletal muscle

by Scott K. Crawford, Kenneth S. Lee, Greg R. Bashford, Bryan C. Heiderscheit

Spatial frequency analysis (SFA) is a quantitative ultrasound (US) method originally developed to assess intratendinous tissue structure. This method may also be advantageous in assessing other musculoskeletal tissues. Although SFA has been shown to be a reliable assessment strategy in tendon tissue, its reliability in muscle has not been investigated. The purpose of this study was to examine the reliability of spatial frequency parameter measurement for a large muscle group within a healthy population. Ten participants with no history of lower extremity surgery or hamstring strain injury volunteered. Longitudinal B-mode images were collected in three different locations across the hamstring muscles. Following a short rest, the entire imaging procedure was repeated. B-mode images were processed by manually drawing a region of interest (ROI) about the entire muscle thickness. Four spatial frequency parameters of interest were extracted from the image ROIs. Intra- and inter-rater reliabilities of extracted SFA parameters were performed. Test-retest reliability of the image acquisition procedure was assessed between repeat trials. Intraclass correlation coefficients showed high intra- and inter-rater reliability (ICC(3,1) > 0.9 for all parameters) and good to moderate test-retest reliability (ICC(3,1) > 0.50) between trials. No differences in parameter values were observed between trials across all muscles and locations (p > 0.05). The high reliability metrics suggest that SFA will be useful for future studies assessing muscle tissue structure, and may have value in assessing muscular adaptations following injury and during recovery.

Characteristics of and Factors Influencing College Nursing Students' Willingness to Utilize mHealth for Health Promotion

imageMore than half of practicing nurses have suboptimal physical or mental health. Impaired health is associated with a 76% higher likelihood that nurses will make medical errors. Improving the health habits of nursing students is essential to shaping and sustaining health prior to joining the workforce. Technology such as mobile health applications holds great promise in facilitating behavioral change and encouraging healthy habits in nursing students. Identifying the predictors of willingness to use mobile health is essential to creating mobile health applications that will engage nursing students and promote sustainable usage. Evaluation of psychological, attitudinal, and health-related correlates of mobile health can highlight predictors of willingness to use mobile health, which can influence nursing students' utilization and long-term engagement with mobile health applications. Analysis of these correlates shows that psychological attributes, such as hope, play a role in the willingness to use and may facilitate engagement in the utilization of a mobile health application. Development of a mobile health application that increases hope and helps establish healthy habits may enable nursing students to remain healthy throughout their lives, creating a new generation of happier, healthier nurses and, ultimately, improving safety for patients under their care.

Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

Por: Johnston · M. C. · Black · C. · Mercer · S. W. · Prescott · G. J. · Crilly · M. A.
Objectives

Multimorbidity is the coexistence of two or more health conditions in an individual. Multimorbidity in younger adults is increasingly recognised as an important challenge. We assessed the prevalence of secondary care multimorbidity in mid-life and its association with premature mortality over 15 years of follow-up, in the Aberdeen Children of the 1950s (ACONF) cohort.

Method

A prospective cohort study using linked electronic health and mortality records. Scottish ACONF participants were linked to their Scottish Morbidity Record hospital episode data and mortality records. Multimorbidity was defined as two or more conditions and was assessed using healthcare records in 2001 when the participants were aged between 45 and 51 years. The association between multimorbidity and mortality over 15 years of follow-up (to ages 60–66 years) was assessed using Cox proportional hazards regression. There was also adjustment for key covariates: age, gender, social class at birth, intelligence at age 7, secondary school type, educational attainment, alcohol, smoking, body mass index and adult social class.

Results

Of 9625 participants (51% males), 3% had multimorbidity. The death rate per 1000 person-years was 28.4 (95% CI 23.2 to 34.8) in those with multimorbidity and 5.7 (95% CI 5.3 to 6.1) in those without. In relation to the reference group of those with no multimorbidity, those with multimorbidity had a mortality HR of 4.5 (95% CI 3.4 to 6.0) over 15 years and this association remained when fully adjusted for the covariates (HR 2.5 (95% CI 1.5 to 4.0)).

Conclusion

Multimorbidity prevalence was 3% in mid-life when measured using secondary care administrative data. Multimorbidity in mid-life was associated with premature mortality.

Assessing the effect of closed-loop insulin delivery from onset of type 1 diabetes in youth on residual beta-cell function compared to standard insulin therapy (CLOuD study): a randomised parallel study protocol

Por: Boughton · C. · Allen · J. M. · Tauschmann · M. · Hartnell · S. · Wilinska · M. E. · Musolino · G. · Acerini · C. L. · Dunger · P. D. · Campbell · F. · Ghatak · A. · Randell · T. · Besser · R. · Trevelyan · N. · Elleri · D. · Northam · E. · Hood · K. · Scott · E. · Lawton · J. · Roze · S.
Introduction

Management of newly diagnosed type 1 diabetes (T1D) in children and adolescents is challenging for patients, families and healthcare professionals. The objective of this study is to determine whether continued intensive metabolic control using hybrid closed-loop (CL) insulin delivery following diagnosis of T1D can preserve C-peptide secretion, a marker of residual beta-cell function, compared with standard multiple daily injections (MDI) therapy.

Methods and analysis

The study adopts an open-label, multicentre, randomised, parallel design, and aims to randomise 96 participants aged 10–16.9 years, recruited within 21 days of diagnosis with T1D. Following a baseline mixed meal tolerance test (MMTT), participants will be randomised to receive 24 months treatment with conventional MDI therapy or with CL insulin delivery. A further 24-month optional extension phase will be offered to all participants to continue with the allocated treatment. The primary outcome is the between group difference in area under the stimulated C-peptide curve (AUC) of the MMTT at 12 months post diagnosis. Analyses will be conducted on an intention-to-treat basis. Key secondary outcomes are between group differences in time spent in target glucose range (3.9–10 mmol/L), glycated haemoglobin (HbA1c) and time spent in hypoglycaemia (

Ethics and dissemination

Ethics approval has been obtained from Cambridge East Research Ethics Committee. The results will be disseminated by peer-reviewed publications and conference presentations.

Trial registration number

NCT02871089; Pre-results.

Examining social isolation and loneliness in combination in relation to social support and psychological distress using Canadian Longitudinal Study of Aging (CLSA) data

by Verena H. Menec, Nancy E. Newall, Corey S. Mackenzie, Shahin Shooshtari, Scott Nowicki

Background

Although a large body of research has focused on social isolation and loneliness, few studies have examined social isolation and loneliness together. The objectives of this study were to examine: 1) the relationship between four groups derived from combining social isolation and loneliness (socially isolated and lonely; only socially isolated; only lonely; neither socially isolated nor lonely) and the desire for more social participation, and social support; and 2) the relationship between the four groups and psychological distress.

Methods

The study was based on the Comprehensive Cohort of the Canadian Longitudinal Study on Aging. Using CLSA baseline data (unweighted N = 30,079), ordinary and logistic regression analysis was used to examine the cross-sectional relationship between the four social isolation/loneliness groups and desire for more social participation and four types of social support (tangible, positive interaction, affection, and emotional support). Prospective logistic regression analysis was possible for psychological distress, which was derived from the Maintaining Contact Questionnaire administered about 18 months after the baseline questionnaire (unweighted N = 28,789).

Results

Findings indicate that being socially isolated and lonely was associated with the most social support gaps; this group also had an increased likelihood of psychological distress, relative to those who were neither socially isolated nor lonely. Participants who were only socially isolated, and those only lonely also perceived some social support gaps. In addition, the only lonely group was more likely to be psychologically distressed than the only socially isolated group and the neither isolated nor lonely group.

Conclusion

Examining the four social isolation/loneliness was useful, as it provided more nuanced risk profiles than would have been possible had we examined social isolation and loneliness separately. Findings may suggest avenues for interventions tailored to the unique needs of at-risk individuals.

Randomised feasibility trial of the helping families programme-modified: an intensive parenting intervention for parents affected by severe personality difficulties

Por: Day · C. · Briskman · J. · Crawford · M. J. · Foote · L. · Harris · L. · Boadu · J. · McCrone · P. · McMurran · M. · Michelson · D. · Moran · P. · Mosse · L. · Scott · S. · Stahl · D. · Ramchandani · P. · Weaver · T.
Background

Specialist parenting intervention could improve coexistent parenting and child mental health difficulties of parents affected by severe personality difficulties.

Objective

Conduct a feasibility trial of Helping Families Programme-Modified (HFP-M), a specialist parenting intervention.

Design

Pragmatic, mixed-methods trial, 1:1 random allocation, assessing feasibility, intervention acceptability and outcome estimates.

Settings

Two National Health Service health trusts and local authority children’s social care.

Participants

Parents: (i) primary caregiver, (ii) 18 to 65 years, (iii) severe personality difficulties, (iv) proficient English and (v) capacity for consent. Child: (i) 3 to 11 years, (ii) living with index parent and (iii) significant emotional/behavioural difficulties.

Intervention

HFP-M: 16-session home-based intervention using parenting and therapeutic engagement strategies. Usual care: standard care augmented by single psychoeducational parenting session.

Outcomes

Primary feasibility outcome: participant retention rate. Secondary outcomes: (i) rates of recruitment, eligibility and data completion, and (ii) rates of intervention acceptance, completion and alliance (Working Alliance Inventory-Short Revised). Primary clinical outcome: child behaviour (Eyberg Child Behaviour Inventory). Secondary outcomes: child mental health (Concerns About My Child, Child Behaviour Checklist-Internalising Scale), parenting (Arnold-O’Leary Parenting Scale, Kansas Parental Satisfaction Scale) and parent mental health (Symptom-Checklist-27). Quantitative data were collected blind to allocation.

Results

Findings broadly supported non-diagnostic selection criterion. Of 48 participants recruited, 32 completed post-intervention measures at mean 42 weeks later. Participant retention exceeded a priori rate (HFP-M=18; Usual care=14; 66.7%, 95% CI 51.6% to 79.6%). HFP-M was acceptable, with delivery longer than planned. Usual care had lower alliance rating. Child and parenting outcome effects detected across trial arms with potential HFP-M advantage (effect size range: 0.0 to 1.3).

Conclusion

HFP-M is an acceptable and potentially effective specialist parenting intervention. A definitive trial is feasible, subject to consideration of recruitment and retention methods, intervention efficiency and comparator condition. Caution is required in interpretation of results due to reduced sample size. No serious adverse events reported.

Trial registration number

ISRCTN14573230

Front‐line nurses' perceptions of intra‐hospital handover

Abstract

Aim and objective

To explore nurses' perceptions of factors that help or hinder intra‐hospital handover.

Background

Miscommunication during clinical handover is a leading cause of clinical incidents in hospitals. Intra‐hospital nursing handover between the emergency department and inpatient unit is particularly complex.

Design

A descriptive, qualitative study. This research adheres to the consolidated criteria for reporting qualitative research.

Methods

Forty‐nine nurses participated in group interviews, which were analysed using inductive content analysis.

Results

Three categories emerged: (a) “lacking clear responsibilities for who provides handover”; (b) “strategies to ensure continuity of information”; and (c) “strained relationships during handover.”

Conclusions

Intra‐hospital handover requires clear processes, to promote high‐quality information sharing. Ensuring these processes are broad and acceptable across units may ensure nurses' needs are met. Relational continuity between nurses is an important consideration when improving intra‐hospital handover.

Relevance to clinical practice

Nursing managers are optimally positioned to enhance intra‐hospital handover, by liaising and enforcing standardisation of processes across units. Nurse managers could promote intra‐unit activities that foster front‐line nurses' communication with each other, to encourage problem‐solving and partnerships.

Perspectives of residents and staff regarding food choice in residential aged care: A qualitative study

Abstract

Aims and objectives

To explore the experiences of food choice and meal service in residential aged care facilities and its impact on autonomy, self‐determination and quality of life from the perspectives of both residents and staff.

Background

Globally, residential aged care is a principal provider of care for older people who can no longer live independently at home. Within this setting, lack of food choice has been identified as a significant factor impacting on residents' self‐determination, sense of autonomy and quality of life.

Design

This study used an exploratory descriptive qualitative approach guided by self‐determination theory.

Method

A total of 14 participants (seven residents and seven staff members) from two Australian residential aged care facilities were recruited through purposive and snowball sampling with assistance from one independent contact nurse at each facility. In‐depth, semi‐structured interviews were conducted, digitally recorded and transcribed. The COREQ checklist was used in this qualitative study.

Results

Three main themes were identified from the interview data provided by residents and staff, which were as follows: (a) catering for the masses; (b) organisational barriers to providing choice; and (c) food impacts well‐being.

Conclusions

This study explored the experiences of food choice and service in residential aged care facilities, from the perspectives of both residents and staff. Results of interviews highlighted the importance of providing adequate food choice which has become an enduring issue that requires more attention and commitment to make a positive change for residents living in residential aged care facilities.

Relevance to clinical practice

Nurses and other staff working in residential aged care facilities need to be aware of the importance of providing adequate food choice, including for residents who require modified diets. As advocates for residents, nursing staff must address the persistent lack of food choice. However, this will require a radical change in organisational culture and strong leadership.

Fading confidence: A qualitative exploration of parents’ experiences caring for a febrile child

Abstract

Aims and objectives

To explore parents’ experiences with paediatric fever to understand their needs for information and support.

Background

Paediatric fever is a normal part of childhood, and multiple episodes of fever are a common occurrence between infancy and adulthood. Despite this expectation, paediatric fever often sparks fear and anxiety amongst parents. Existing research has primarily focused on measuring parental deficits, so a more in‐depth exploration is helpful to understand the complexities of caring for a febrile child.

Design

Qualitative descriptive study.

Methods

Purposive sampling of N = 15 parents from a paediatric emergency department presenting with a febrile child. Semi‐structured interviews were conducted in‐person or via telephone. Thematic analysis was used to understand the data in the light of our research question. Reporting follows the consolidated criteria for reporting qualitative research checklist.

Results

We found themes of (a) parental confidence through caregiving tasks, (b) emergent feelings of inadequacy, (i) referrals and limitations of community practice, (c) information needs and (d) information sources. Whereas parents were initially confident accessing information, providing care, making decisions and managing symptoms, new signs/symptoms sparked a change in parents’ emotions, coping and behaviour. Parents routinely search for information about paediatric fever and value reliable, accessible resources.

Conclusions

Our findings highlight parents’ strengths assessing fever and effectively managing symptoms. We are encouraged by the potential for these results to inform the development of empowering resources to help parents make child health decisions during paediatric fever.

Relevance to clinical practice

Findings provide an evidence base for researchers, clinicians and policymakers to improve care for paediatric patients and families. Parents want clear, reliable and accessible information about decision points associated with paediatric fever. Resources with an empowerment focus may help parents maintain a sense of control when caring for a febrile child.

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings

Abstract

Aims and objective

To capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer.

Background

Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus and cancer. There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting. Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting.

Method

An exploratory, descriptive study was employed using focus groups to gather narrative data, which was then subject to qualitative analysis. Eleven mental health inpatient wards within a local health district in Sydney, Australia, were studied, comprising ward‐based nurses (n = 64) and nurse unit managers (n = 8). This paper follows the COREQ guidelines for reporting qualitative health research.

Results

Qualitative data analysis revealed three themes central to the nurses' experience: (a) lack of clarity (subthemes: procedures and leadership accountability); (b) confidence in the workforce (subthemes: knowledge and skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and (c) complexity (subthemes: complexity as the new norm and suitability of the mental health environment).

Conclusion

The themes found in this study can be used to guide and inform healthcare policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer.

Relevance to clinical practice

Findings provide a rich data set for the generation of measurement tools and protocols to guide physical health care and evaluate performance.

Road to recovery: a study protocol quantifying neurological outcome in cardiac surgery patients and the role of cerebral oximetry

Por: Semrau · J. S. · Scott · S. H. · Hamilton · A. G. · Petsikas · D. · Payne · D. M. · Bisleri · G. · Saha · T. · Boyd · J. G.
Introduction

Patients undergoing cardiac surgery may experience both short-term and long-term postoperative neurological problems. However, the underlying cause of this impairment is unclear. Regional cerebral oxygen saturation (rSO2) levels may play a role in the development of acute dysfunction, known as postoperative delirium, in addition to longer term outcomes after cardiac surgery. Yet the degree of impairment has been difficult to define, partly due to subjective methods of assessments. This study aims to fill this knowledge gap by determining the relationship between rSO2, postoperative delirium and long-term neurological outcome after cardiac surgery using quantitative robotic technology.

Methods and analysis

95 patients scheduled for elective cardiac surgery will be recruited for this single-centre prospective observational study. Patients will be assessed before as well as 3 and 12 months after their surgery using the Kinarm End-Point Lab and standardised tasks. Intraoperatively, rSO2 and other haemodynamic data will be collected for the duration of the procedure. Following their operation, patients will also be screened daily for delirium during their hospital stay.

Ethics and dissemination

This study has been approved by the Health Sciences Research Ethics Board at Queen’s University (DMED-1672–14). The results of this study will be published in a peer-review journal and presented at international and/or national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication.

Trial registration number

NCT04081649

Understanding Determinants of Sustainability Through a Realist Investigation of a Large‐Scale Quality Improvement Initiative (Lean): A Refined Program Theory

Abstract

Background

Implementation science research seeks to understand ways to best ensure uptake of research‐based initiatives to health care; however, there is little research done on how to sustain such efforts. Sustainability is the degree to which an initiative continues to be used in practice after efforts of implementation have ended. Sustainability research is a growing field of implementation science that needs further research to understand how to predict and measure the long‐term use of effective initiatives to improve health care. The question of what influences the sustainability of research‐based initiatives to improve health care remains unknown.

Purpose

The purpose of this article was to present a refined program theory on the contextual factors and mechanisms that influence the sustainability of one large‐scale quality management initiative (Lean) in pediatric health care.

Design

We conducted a multiphase realist investigation to explain under what contexts, for whom, how, and why Lean efforts are sustained or not sustained in pediatric health care through the generation of an explanatory program theory.

Methods

This article presents the theoretical triangulation of our multiphase realist investigation, resulting in a refined program theory. We integrated the initial program theories (IPTs) from each research phase to form a refined program theory. It involved going back and forth from the initial IPT to the findings from each phase and our middle‐range theories and examining the most substantiated IPTs on the contextual factors and mechanisms that influenced the sustainability of Lean efforts.

Findings

The refined program theory depicts the complex nature to sustaining Lean efforts and that sustainability as a small, often unrepresentative portion of something much larger or more complex that cannot yet be seen or understood. The approach and nature of implementation is critical to shaping contexts for sustainability. Outcomes from implementation become facilitating or hindering contexts for sustainability. Customization to context is an important contextual factor for sustainability. Sense making, value congruency, and staff engagement are critical aspects from early implementation that enable or hinder processes of sustainment. Such mechanisms can trigger staff empowerment that can lead to a greater likelihood of sustainability.

Conclusions

These findings have important implications for sustainability research, in understanding the determinants of sustainability of research‐based initiatives in health care.

Clinical Relevance

It is important to understand and explain determinants of sustainability through theory‐driven evaluative research in order to assist key stakeholders in sustaining the effective research‐based initiatives made to improve healthcare services, patient care, and outcomes.

Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces

Por: Martin-Misener · R. · Wong · S. T. · Johnston · S. · Blackman · S. · Scott · C. · Hogg · W. · Burge · F. · Grool · A. M. · Campbell · J. L. · Wuite · S.
Objective

To explore regional primary care improvement strategies that are potentially determinants of primary care performance.

Design

Multiple comparative embedded case study.

Setting

Three regions in Canada: Fraser East, British Columbia; Eastern Ontario Health Unit, Ontario; Central Zone, Nova Scotia.

Data sources

(1) In-depth interviews with purposively selected key informants (eg, primary care decision-makers, physician leads, regulatory agencies) and focus groups with patients and clinicians (n=68 participants) and (2) published and grey literature (n=205 documents).

Outcome measures

Variations in spread and uptake of primary care improvement strategies across the three study regions. NVivo (V.11) was used to manage data and perform content analysis to identify categories within and across cases. The coding structure was developed by researchers through iterative collaboration, using inductive and deductive processes.

Results

Six overarching primary care improvement strategies, differing in focus and spread, were implemented across the three study regions: interprofessional team-based approaches, provider skill mix expansion, physician groups and networks, information systems, remuneration and performance measurement and reporting infrastructure.

Conclusion

The addition of information on regional improvement strategies to primary care performance reports could add important contextual insights into primary care performance results. This could help identify possible drivers of reported performance outcomes and levers for change in practice, regional and system-level settings.

The NoHoW protocol: a multicentre 2x2 factorial randomised controlled trial investigating an evidence-based digital toolkit for weight loss maintenance in European adults

Por: Scott · S. E. · Duarte · C. · Encantado · J. · Evans · E. H. · Harjumaa · M. · Heitmann · B. L. · Horgan · G. W. · Larsen · S. C. · Marques · M. M. · Mattila · E. · Matos · M. · Mikkelsen · M.-L. · Palmeira · A. L. · Pearson · B. · Ramsey · L. · Sainsbury · K. · Santos · I. · Sniehotta
Introduction

Obesity and associated diseases place a severe burden on healthcare systems. Behavioural interventions for weight loss (WL) are successful in the short term but often result in weight regain over time. Self-regulation of eating and activity behaviours may significantly enhance weight loss maintenance (WLM) and may be effectively augmented by contextual behavioural approaches to emotion regulation. The NoHoW trial tests the efficacy of a theoretically informed, evidence-based digital toolkit using a mobile-enabled website, activity trackers and Wi-Fi scales for WLM aiming to target (1) self-regulation and motivation, and (2) emotion regulation in adults who achieved clinically significant (≥5%) WL in the previous 12 months (initial body mass index (BMI) ≥25 kg/m2).

Methods and analysis

The study is an 18-month, 3-centre, 2x2 factorial single-blind, randomised controlled trial, which recruited 1627 participants achieving ≥5% WL between March 2017 and March 2018. Participants are randomly allocated to one of four arms: (1) self-monitoring only (self-weighing and activity tracker), (2) self-regulation and motivation, (3) emotion regulation or (4) combined self-regulation, motivation and emotion regulation. Participants attend four clinical investigation days at 0, 6, 12 and 18 months and are instructed to use the digital toolkit for 18 weeks during the first 6 months and at their discretion for the remaining 12 months. The primary outcome is change in weight (kg) at 12 months from baseline. Secondary outcomes are body composition (eg, bioimpedance analysis), health biomarkers (glycated haemoglobin, lipids, blood pressure, hair cortisol), dietary intake, physical activity, sleep, motivational, self-regulatory, emotion regulatory moderators/mediators of WLM, engagement, user experience, acceptability and cost-effectiveness of the interventions.

Ethics and dissemination

Ethical approval was granted by Institutional Ethics Committees at the Universities of Leeds (17–0082; 27 February 2017), Lisbon (17/2016; 20 February 2017) and Capital Region of Denmark (H-16030495, 8 March 2017). Results will be published in scientific journals.

Trial registration number

ISRCTN88405328.

Using population-wide administrative and laboratory data to estimate type- and subtype-specific influenza vaccine effectiveness: a surveillance protocol

Por: Scott · A. N. · Buchan · S. A. · Kwong · J. C. · Drews · S. J. · Simmonds · K. A. · Svenson · L. W.
Introduction

The appropriateness of using routinely collected laboratory data combined with administrative data for estimating influenza vaccine effectiveness (VE) is still being explored. This paper outlines a protocol to estimate influenza VE using linked laboratory and administrative data which could act as a companion to estimates derived from other methods.

Methods and analysis

We will use the test-negative design to estimate VE for each influenza type/subtype and season. Province-wide individual-level records of positive and negative influenza tests at the Provincial Laboratory for Public Health in Alberta will be linked, by unique personal health numbers, to administrative databases and vaccination records held at the Ministry of Health in Alberta to determine covariates and influenza vaccination status, respectively. Covariates of interests include age, sex, immunocompromising chronic conditions and healthcare setting. Cases will be defined based on an individual’s first positive influenza test during the season, and potential controls will be defined based on an individual’s first negative influenza test during the season. One control for each case will be randomly selected based on the week the specimen was collected. We will estimate VE using multivariable logistic regression.

Ethics and dissemination

Ethics approval was obtained from the University of Alberta’s Health Research Ethics Board—Health Panel under study ID Pro00075997. Results will be disseminated by public health officials in Alberta.

What are the important design features of personal health records to improve medication adherence for patients with long-term conditions? A systematic literature review

Por: Andrikopoulou · E. · Scott · P. · Herrera · H. · Good · A.
Objectives

This systematic literature review aims to identify important design features of the electronic personal health record (PHR) that may improve medication adherence in the adult population with long-term conditions.

Data sources

PubMed (including MEDLINE), CINAHL, Science Direct (including EMBASE), BioMed Central, ACM digital, Emerald Insight, Google Scholar and Research Gate.

Methods

Studies that were published between 1 January 2002 and 31 May 2018 in English were included if the participants were adults, with at least one long-term condition, were able to self-administer their medication and were treated in primary care settings. The quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and the risk of bias was appraised using the Cochrane risk of bias tool.

Results

From a total of 27 studies that matched the inclusion criteria, 12 were excluded due to low quality of evidence, 10 were rated moderate and 5 were rated high quality. All the included studies had low sample size and limited follow-up duration. Thirteen of the included studies found that the use of a PHR has increased medication adherence. The identified design features are reminders, education, personalisation and tailoring, feedback and alerts, gamification, medication management, medical appointment management, diary and self-monitoring, health condition management, set goals, patient’s blog and tethered. It was impossible to draw conclusions as to which feature is important to what group of patients and why. The most frequently identified conditions were HIV and diabetes. This review did not identify any papers with negative results. It was not possible to numerically aggregate the PHR effect due to high heterogeneity of the medication adherence measurement, study type, participants and PHRs used.

Conclusion

Although we found recurrent evidence that PHRs can improve medication adherence, there is little evidence to date to indicate which design features facilitate this process.

PROSPERO registration number

CRD42017060542.

Perceptions and experiences of perioperative nurses and nurse anaesthetists in robotic‐assisted surgery

Abstract

Aims and objectives

To explore the perceptions and experiences of perioperative nurses and Certified Registered Nurse Anaesthetists (CRNAs) in robotic‐assisted laparoscopic surgery (RALS). The objective was to identify the factors that affect nursing care of patients who undergo robotic‐assisted laparoscopic surgery (RALS).

Background

The rapid introduction of technological innovations into the healthcare system has created new challenges for perioperative nurses. RALS affects the physical and interpersonal context of the surgical team's work and subsequent patient outcomes. Despite significant changes to the workflow for perioperative nurses and CRNAs, there is little research focusing on the nurses’ experience and their challenges with RALS.

Design

A qualitative descriptive study.

Method

Semi‐structured interview questions guided data collection. A total of seventeen participants including six preoperative and postoperative nurses, seven intraoperative nurses, and four CRNAs in the United States were interviewed. The interviews were conducted between 26 April–24 June 2018. Data were analysed using thematic analysis, and the COREQ checklist was used to report data collection, analysis and the results.

Results

Three major themes and two categories within each theme were identified: (a) surgical innovation: nurse perception and workflow; (b) interprofessional practice: teamwork and standards; and (c) outcome: patient outcomes and system outcomes.

Conclusions

The findings indicate that RALS has the potential to improve patient outcomes when performed in a timely fashion by skilled surgeons, and efficient, well‐trained surgical teams. For patients to experience full benefits of RALS, patient characteristics, the underlying reason for surgery, and cost must be considered.

Relevance to clinical practice

The results of this study highlight the necessity of promoting factors that improve the surgical team training and practice for RALS and will ultimately impact patient outcomes.

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