Search

Background: The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK. Methods: A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR). Results: Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services. Conclusions: Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people. [ABSTRACT FROM AUTHOR]

Purpose: Limited examples exist of successful Patient Reported Outcome Measure (PROM) implementation across an entire healthcare organisation. The aim of this study was to use a multi-stakeholder co-design process to develop a PROM collection system, which will inform implementation of routine collection of PROMs across an entire healthcare organisation. Methods: Co-design comprised semi-structured interviews with clinicians (n = 11) and workshops/surveys with consumers (n = 320). The interview guide with clinicians focused on their experience using PROMs, preferences for using PROMs, and facilitators/barriers to using PROMs. Co-design activities specific to consumers focused on: (1) how PROMs will be administered (mode), (2) when PROMs will be administered (timing), (3) who will assist with PROMs collection, and (4) how long a PROM will take to complete. Data were analysed using a manifest qualitative content analysis approach. Results: Core elements identified during the co-design process included: PROMs collection should be consumer-led and administered by someone other than a clinician; collection at discharge from the healthcare organisation and at 3–6 months post discharge would be most suitable for supporting comprehensive assessment; PROMs should be administered using a variety of modes to accommodate the diversity of consumer preferences, with electronic as the default; and the time taken to complete PROMs should be no longer than 5–10 min. Conclusion: This study provides new information on the co-design of a healthcare organisation-wide PROM collection system. Implementing a clinician and patient informed strategy for PROMs collection, that meets their preferences across multiple domains, should address known barriers to routine collection. [ABSTRACT FROM AUTHOR]

Background: Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes. Method: We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1st January 1995 to 15th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category. Results: Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results. Conclusions: Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base. Trial registration: CRD42019119429. [ABSTRACT FROM AUTHOR]

To identify client and service factors associated with changes in health-related quality of life following community rehabilitation. We conducted a retrospective observational cohort study within a community rehabilitation program. Health-related quality of life was measured using the EuroQol five Dimensions, five response level version (EQ-5D-5L). Our primary outcome was the Visual Analogue Scale (VAS) rating of overall health. Analyses were stratified by diagnostic group: traumatic orthopaedic, elective orthopaedic, neurological, medical, and other. The association between client and service factors and discharge VAS scores, adjusted for baseline scores were determined using multivariable regression. EQ-5D-5L data were available for 981 of 1350 participants. Treatment intensity was associated with a seven-point increase (β = 7.22, 95%CI 2.28–12.2, p = 0.004) in VAS scores for traumatic orthopaedic participants. For neurological participants, there was a positive interaction between comorbidities and intensity of therapy (β = 7.9, 95%CI 2.75–13.1, p = 0.003), indicating that greater therapy intensity in those with higher comorbidity scores was associated with an improvement in VAS scores. Age was negatively associated with VAS scores for traumatic orthopaedic participants and socioeconomic status was positively associated with VAS scores for elective orthopaedic participants. Treatment intensity is a modifiable service factor that may positively influence health-related quality of life. In addition to providing information on client progress towards attainment of individual treatment goals, routine collection of patient reported outcome measures within a community rehabilitation program can elicit information that can inform rehabilitation service improvement. Clients of a community rehabilitation program with a neurological or medical condition demonstrate the least improvement in overall health profile and may require additional rehabilitation or supports. Across all diagnostic groups, problems with anxiety and depression were least likely to improve following receipt of community rehabilitation. Improving access to psychological services and associated referral pathways in community rehabilitation services could improve these outcomes. Initiatives aimed at increasing intensity of therapy such as targeted triage and resource allocation, may improve health-related quality of life for clients of a community rehabilitation program with traumatic orthopaedic conditions. For clients with a neurological condition, initiatives aimed at increasing intensity of therapy may improve health-related quality of life in more complex patients with comorbid health conditions. [ABSTRACT FROM AUTHOR]

Objective: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. Design: This was a prospective observational cohort study. Setting: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. Subjects: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. Methods: We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. Measures: Dose of rehabilitation – time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. Results: We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7–7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7–3.8) compared to no rehabilitation, after adjustment for baseline factors. Conclusion: Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation. [ABSTRACT FROM AUTHOR]

Rationale: The effectiveness of clinician-focused interventions to improve stroke care is uncertain. Aims: To determine whether an organizational intervention can improve the quality of stroke care over usual care. Sample size estimates: To detect an absolute 10% difference in overall performance (composite outcome), a minimum of 21 hospitals and 843 patients per group was determined. Methods and design: Before and after controlled design in hospitals in Queensland, Australia. Intervention: Externally facilitated program (StrokeLink) using outreach workshops incorporating clinical performance feedback, patient outcomes (survival, quality of life at 90-180 days), local barrier assessments to best practice care, action planning, and ongoing support. Descriptive and multivariable analyses adjusted for patient correlations by hospital (intention-to-treat method). Context: Concurrent implementation of financial incentives to increase stroke unit access and use of the Australian Stroke Clinical Registry for performance monitoring. Study outcome(s): Primary outcome: net change in composite score (i.e. total number of process indicators achieved divided by the sum of eligible indicators for each cohort). Secondary outcomes: change in individual indicators, change in composite score comparing hospitals that did or did not develop action plans (per-protocol analysis), impact on 90-180-day health outcomes. Sensitivity analyses: hospital self-rated status, alternate cross-sectional audit data (Stroke Foundation). To account for temporal effects, comparison of Queensland hospital performance relative to other Australian hospitals will also be undertaken. Discussion: Twenty-one hospitals were recruited; however, one was unable to participate within the study time frame. Workshops were held between 11 March 2014 and 7 November 2014. Data are ready for analysis. [ABSTRACT FROM AUTHOR]

Background: Evidence of the burden of suboptimal stroke care should expedite quality improvement. We aimed to estimate the health and economic impact of improving acute stroke management to best practice standards using Australia as a case study. Methods: Hospital performance in Australia was estimated using data from the National Stroke Audit of Acute Services 2013. The percentage of patients provided evidence-based therapies in all hospitals was compared to that achieved in the aggregate of top performing benchmark hospitals (that included between them, a minimum contribution of 15% of all cases audited). The number of additional patients who would receive therapies if this performance gap was rectified was applied to a standardized economic simulation model that comprised stroke rates and resource-use estimates from the North East Melbourne Stroke Incidence Study applied to the 2013 Australian population. Results: In 2013, 41,398 patients were estimated to have been hospitalized with stroke. If acute care was improved to that of Australian benchmarks, there would be an additional 15,317 patients accessing stroke units; 1960 receiving thrombolysis; and 4007 being treated with antihypertensive medication, 3082 with antiplatelet medication, 2179 with anticoagulant medication, and 3514 with lipid-lowering therapy. Approximately 9329 disability-adjusted life years could be avoided. This additional care provided would be cost effective at AUD 3304 per disability adjusted life year avoided. Conclusion: The benefits of reducing evidence-practice gaps in Australia are considerable. Further investment in initiatives to optimize hospital care is justified. [ABSTRACT FROM AUTHOR]