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Literature update October 2010

A Clarke, N Blundell, I Forde, N Musila, D Spitzer, S Naqvi, J Browne. Can guidelines improve referral to elective surgical specialties for adults? A systematic review. Qual Saf Health Care 2010;19:187-194

Aim To assess effectiveness of guidelines for referral for elective surgical assessment. Method Systematic review with descriptive synthesis. Data sources Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites. Selection of studies Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults. Outcome measures Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs. Results 24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex (“one-stop shops”) to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change. Conclusions Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.

John N. Lavis, G. Emmanuel Guindon, David Cameron, Boungnong Boupha, Masoumeh Dejman, Eric J.A. Osei, Ritu Sadana for the Research to Policy and Practice Study Team. Bridging the gaps between research, policy and practice in low- and middle-income countries: a survey of researchers. CMAJ 2010;182: E350-E361.

Background: Many international statements have urged researchers,policy-makers and health care providers to collaborate in effortsto bridge the gaps between research, policy and practice inlow- and middle-income countries. We surveyed researchers in10 countries about their involvement in such efforts.Methods: We surveyed 308 researchers who conducted researchon one of four clinical areas relevant to the Millennium DevelopmentGoals (prevention of malaria, care of women seeking contraception,care of children with diarrhea and care of patients with tuberculosis)in each of 10 low- and middle-income countries (China, Ghana,India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal andTanzania). We focused on their engagement in three promisingbridging activities and examined system-level, organizationaland individual correlates of these activities.Results: Less than half of the researchers surveyed reportedthat they engaged in one or more of the three promising bridgingactivities: 27% provided systematic reviews of the researchliterature to their target audiences, 40% provided access toa searchable database of research products on their topic, and43% established or maintained long-term partnerships relatedto their topic with representatives of the target audience.Three factors emerged as statistically significant predictorsof respondents’ engagement in these activities: the existenceof structures and processes to link researchers and their targetaudiences predicted both the provision of access to a database(odds ratio [OR] 2.62, 95% CI 1.30–5.27) and the establishmentor maintenance of partnerships (OR 2.65, 95% CI 1.25–5.64);stability in their contacts predicted the provision of systematicreviews (OR 2.88, 95% CI 1.35–6.13); and having managersand public (government) policy-makers among their target audiencespredicted the provision of both systematic reviews (OR 4.57,95% CI 1.78–11.72) and access to a database (OR 2.55,95% CI 1.20–5.43).Interpretation: Our findings suggest potential areas for improvementin light of the bridging strategies targeted at health careproviders that have been found to be effective in some contextsand the factors that appear to increase the prospects for usingresearch in policy-making.

G. Emmanuel Guindon, John N. Lavis, Francisco Becerra-Posada, Hossein Malek-Afzali, Guang Shi, C. Ashok K. Yesudian, Steven J. Hoffman for the Research to Policy and Practice Study Team. Bridging the gaps between research, policy and practice in low- and middle-income countries: a survey of health care providers. CMAJ 2010;182: E362-E372.

Background: Gaps continue to exist between research-based evidenceand clinical practice. We surveyed health care providers in10 low- and middle-income countries about their use of research-basedevidence and examined factors that may facilitate or impedesuch use. Methods: We surveyed 1499 health care providers practising inone of four areas relevant to the Millennium Development Goals(prevention of malaria, care of women seeking contraception,care of children with diarrhea and care of patients with tuberculosis)in each of China, Ghana, India, Iran, Kazakhstan, Laos, Mexico,Pakistan, Senegal and Tanzania. Results: The proportion of respondents who reported that researchwas likely to change their clinical practice if performed andpublished in their own country (84.6% and 86.0% respectively)was higher than the proportion who reported the same about researchand publications from their region (66.4% and 63.1%) or fromhigh-income countries (55.8% and 55.5%). Respondents who weremost likely to report that the use of research-based evidenceled to changes in their practice included those who reportedusing clinical practice guidelines in paper format (odds ratio[OR] 1.54, 95% confidence interval [CI] 1.03–2.28), usingscientific journals from their own country in paper format (OR1.70, 95% CI 1.26–2.28), viewing the quality of researchperformed in their country as above average or excellent (OR1.93, 95% CI 1.16–3.22); trusting systematic reviews ofrandomized controlled trials (OR 1.59, 95% CI 1.08–2.35);and having easy access to the Internet (OR 1.90, 95% CI 1.19–3.02). Interpretation: Locally conducted or published research hasplayed an important role in changing the professional practiceof health care providers surveyed in low- and middle-incomecountries. Increased investments in local research, or at leastin locally adapted publications of research-based evidence fromother settings, are therefore needed. Although access to theInternet was viewed as a significant factor in whether research-basedevidence led to concrete changes in practice, few respondentsreported having easy access to the Internet. Therefore, effortsto improve Internet access in clinical settings need to be accelerated.

Dawn Craig and Catriona McDaid and Tiago Fonseca and Christian Stock and Steven Duffy and Nerys Woolacott. Are adverse effects incorporated in economic models? A survey of current practice. International Journal of Technology Assessment in Health Care 2010;26(3):323-329.

Background: Clearly the benefits of a treatment must not be outweighed by the adverse effects. If researchers fail to incorporate adverse effects adequately in models, this could limit the validity of the results obtained. In the worst case, interventions that are cost-effective may be shown not to be. The aim of this research was to review current practice when incorporating adverse effects in economic models. Methods: A survey of HTA reports commissioned by the National Institute for Health Research (NIHR) Health Technology Assessment programme, published between 2004 and 2007 was conducted. All reports which investigated the clinical and cost-effectiveness of a health technology using a systematic review and an economic model framework were included. Results: A total of eighty reports met the inclusion criteria. Of the models including adverse effects (43/80), 67 percent used a clinical adverse effects parameter, 79 percent a cost of adverse effects parameter, 86 percent used one of these, and 60 percent used both. Of the thirty-seven models that did not include adverse effects, eighteen justified this omission, most commonly lack of data; nineteen appeared to make no explicit consideration of adverse effects in the model. Conclusions: In many cases, poor reporting made it difficult to ascertain if there had been any consideration of adverse effects. We suggest that the findings of this survey support a call for much clearer and explicit reporting of adverse effects, or their exclusion, in decision models and for explicit recognition in future guidelines that “all relevant outcomes” should include some consideration of adverse events.

Tremblay D, Drouin D, Lang A, Roberge D, Ritchie J, Plante A. Interprofessional collaborative practice within cancer teams: translating evidence into action. A mixed methods study protocol. Implementation Science 2010; 5:53.

Background: A regional integrated cancer network has implemented a program (educational workshops, reflective and mentoring activities) designed to support the uptake of evidence-informed interprofessional collaborative practices (referred to in this text as EIPCP) within cancer teams. This research project, which relates to the Registered Nurses' Association of Ontario (RNAO) Best Practice Guidelines and other sources of research evidence, represents a unique opportunity to learn more about the factors and processes involved in the translation of evidence-based recommendations into professional practices. The planned study seeks to address context-specific challenges and the concerns of nurses and other stakeholders regarding the uptake of evidence-based recommendations to effectively promote and support interprofessional collaborative practices. Aim: This study aims to examine the uptake of evidence-based recommendations from best practice guidelines intended to enhance interprofessional collaborative practices within cancer teams. Design: The planned study constitutes a practical trial, defined as a trial designed to provide comprehensive information that is grounded in real-world healthcare dynamics. An exploratory mixed methods study design will be used. It will involve collecting quantitative data to assess professionals' knowledge and attitudes, as well as practice environment factors associated with effective uptake of evidence-based recommendations. Semi-structured interviews will be conducted concurrently with care providers to gather qualitative data for describing the processes involved in the translation of evidence into action from both the users' (n = 12) and providers' (n = 24) perspectives. The Graham et al. Ottawa Model of Research Use will serve to construct operational definitions of concepts, and to establish the initial coding labels to be used in the thematic analysis of the qualitative data. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interrelated contextual factors that enhance the uptake of EIPCP and changes in professional practices. Discussion: The information obtained from the study will produce new knowledge on the interventions and sources of support most conducive to the uptake of evidence and building of capacity to sustain new interprofessional collaborative practice patterns. It will provide new information on strategies for overcoming barriers to evidence-informed interventions. The findings will also pinpoint critical determinants of 'what works and why' taking into account the interplay between evidence, operational, relational micro-processes of care, uniqueness of patients' needs and preferences, and the local context.

Melissa C. Brouwers, Michelle E. Kho, George P. Browman, Jako S. Burgers, Francoise Cluzeau, Gene Feder, Béatrice Fervers, Ian D. Graham, Steven E. Hanna, Julie Makarski for the AGREE Next Steps Consortium. Development of the AGREE II, part 1: performance, usefulness and areas for improvement. CMAJ 2010 182: 1045-1052.

Background: We undertook research to improve the AGREE instrument,a tool used to evaluate guidelines. We tested a new seven-pointscale, evaluated the usefulness of the original items in theinstrument, investigated evidence to support shorter, tailoredversions of the tool, and identified areas for improvement.Method: We report on one component of a larger study that useda mixed design with four factors (user type, clinical topic,guideline and condition). For the analysis reported in thisarticle, we asked participants to read a guideline and use theAGREE items to evaluate it based on a seven-point scale, tocomplete three outcome measures related to adoption of the guideline,and to provide feedback on the instrument’s usefulnessand how to improve it.Results: Guideline developers gave lower-quality ratings thandid clinicians or policy-makers. Five of six domains were significantpredictors of participants’ outcome measures (p < 0.05).All domains and items were rated as useful by stakeholders (meanscores > 4.0) with no significant differences by user type(p > 0.05). Internal consistency ranged between 0.64 and0.89. Inter-rater reliability was satisfactory. We receivedfeedback on how to improve the instrument.Interpretation: Quality ratings of the AGREE domains were significantpredictors of outcome measures associated with guideline adoption:guideline endorsements, overall intentions to use guidelines,and overall quality of guidelines. All AGREE items were assessedas useful in determining whether a participant would use a guideline.No clusters of items were found more useful by some users thanothers. The measurement properties of the seven-point scalewere promising. These data contributed to the refinements andrelease of the AGREE II.

Melissa C. Brouwers, Michelle E. Kho, George P. Browman, Jako S. Burgers, Françoise Cluzeau, Gene Feder, Béatrice Fervers, Ian D. Graham, Steven E. Hanna, Julie Makarski for the AGREE Next Steps Consortium. Development of the AGREE II, part 2: assessment of validity of items and tools to support application. CMAJ 2010 182: E472-E478.

Background: We established a program of research to improvethe development, reporting and evaluation of practice guidelines.We assessed the construct validity of the items and user’smanual in the β version of the AGREE II.Methods: We designed guideline excerpts reflecting high-andlow-quality guideline content for 21 of the 23 items in thetool. We designed two study packages so that one low-qualityand one high-quality version of each item were randomly assignedto each package. We randomly assigned 30 participants to oneof the two packages. Participants reviewed and rated the guidelinecontent according to the instructions of the user’s manualand completed a survey assessing the manual.Results: In all cases, content designed to be of high qualitywas rated higher than low-quality content; in 18 of 21 cases,the differences were significant (p < 0.05). The manual wasrated by participants as appropriate, easy to use, and helpfulin differentiating guidelines of varying quality, with all scoresabove the mid-point of the seven-point scale. Considerable feedbackwas offered on how the items and manual of the β-AGREEII could be improved.Interpretation: The validity of the items was established andthe user’s manual was rated as highly useful by users.We used these results and those of our study presented in part1 to modify the items and user’s manual. We recommendAGREE II (available at www.agreetrust.org) as the revised standardfor guideline development, reporting and evaluation.

Shariff SZ, Cuerden MS, Haynes R, McKibbon K, Wilczynski NL, Iansavichus AV, Speechley MR, Thind A, Garg AX. Evaluating the impact of MEDLINE filters on evidence retrieval: study protocol. Implementation Science 2010;5:58.

Background: Rather than searching the entire MEDLINE database, clinicians can perform searches on a filtered set of articles where relevant information is more likely to be found. Members of our team previously developed two types of MEDLINE filters. The ‘methods’ filters help identify clinical research of high methodological merit. The ‘content’ filters help identify articles in the discipline of renal medicine. We will now test the utility of these filters for physician MEDLINE searching. Hypothesis: When a physician searches MEDLINE, we hypothesize the use of filters will increase the number of relevant articles retrieved (increase ‘recall,’ also called sensitivity) and decrease the number of non-relevant articles retrieved (increase ‘precision,’ also called positive predictive value), compared to the performance of a physician’s search unaided by filters. Methods: We will survey a random sample of 100 nephrologists in Canada to obtain the MEDLINE search that they would first perform themselves for a focused clinical question. Each question we provide to a nephrologist will be based on the topic of a recently published, well-conducted systematic review. We will examine the performance of a physician’s unaided MEDLINE search. We will then apply a total of eight filter combinations to the search (filters used in isolation or in combination). We will calculate the recall and precision of each search. The filter combinations that most improve on unaided physician searches will be identified and characterized. Discussion: If these filters improve search performance, physicians will be able to search MEDLINE for renal evidence more effectively, in less time, and with less frustration. Additionally, our methodology can be used as a proof of concept for the evaluation of search filters in other disciplines.

Ganann R, Ciliska D, Thomas H. Expediting systematic reviews: methods and implications of rapid reviews. Implementation Science 2010;5:56.

Background: Policy makers and others often require synthesis of knowledge in an area within six months or less. Traditional systematic reviews typically take at least 12 months to conduct. Rapid reviews streamline traditional systematic review methods in order to synthesize evidence within a shortened timeframe. There is great variation in the process of conducting rapid reviews. This review sought to examine methods used for rapid reviews, as well as implications of methodological streamlining in terms of rigour, bias, and results. Methods: A comprehensive search strategy--including five electronic databases, grey literature, hand searching of relevant journals, and contacting key informants--was undertaken. All titles and abstracts (n = 1,989) were reviewed independently by two reviewers. Relevance criteria included articles published between 1995 and 2009 about conducting rapid reviews or addressing comparisons of rapid reviews versus traditional reviews. Full articles were retrieved for any titles deemed relevant by either reviewer (n = 70). Data were extracted from all relevant methodological articles (n = 45) and from exemplars of rapid review methods (n = 25). Results: Rapid reviews varied from three weeks to six months; various methods for speeding up the process were employed. Some limited searching by years, databases, language, and sources beyond electronic searches. Several employed one reviewer for title and abstract reviewing, full text review, methodological quality assessment, and/or data extraction phases. Within rapid review studies, accelerating the data extraction process may lead to missing some relevant information. Biases may be introduced due to shortened timeframes for literature searching, article retrieval, and appraisal. Conclusions: This review examined the continuum between diverse rapid review methods and traditional systematic reviews. It also examines potential implications of streamlined review methods. More of these rapid reviews need to be published in the peer-reviewed literature with an emphasis on articulating methods employed. While one consistent methodological approach may not be optimal or appropriate, it is important that researchers undertaking reviews within the rapid to systematic continuum provide detailed descriptions of methods used and discuss the implications of their chosen methods in terms of potential bias introduced. Further research comparing full systematic reviews with rapid reviews will enhance understanding of the limitations of these methods.

Schultz TJ, Kitson AL . Measuring the context of care in an Australian acute care hospital: a nurse survey. Implementation Science 2010;5:60

Background: This study set out to achieve three objectives: to test the application of a context assessment tool in an acute hospital in South Australia; to use the tool to compare context in wards that had undergone an evidence implementation process with control wards; and finally to test for relationships between demographic variables (in particular experience) of nurses being studied (n = 422) with the dimensions of context. Methods: The Alberta Context Tool (ACT) was administered to all nursing staff on six control and six intervention wards. A total of 217 (62%) were returned (67% from the intervention wards and 56% from control wards). Data were analysed using Stata (v9). The effect of the intervention was analysed using nested (hierarchical) analysis of variance; relationships between nurses’ experience and context was examined using canonical correlation analysis. Results: Results confirmed the adaptation and fit of the ACT to one acute care setting in South Australia. There was no difference in context scores between control and intervention wards. However, the tool identified significant variation between wards in many of the dimensions of context. Though significant, the relationship between nurses’ experience and context was weak, suggesting that at the level of the individual nurse, few factors are related to context. Conclusions: Variables operating at the level of the individual showed little relationship with context. However, the study indicated that some dimensions of context (e.g., leadership, culture) vary at the ward level, whereas others (e. g., structural and electronic resources) do not. The ACT also raised a number of interesting speculative hypotheses around the relationship between a measure of context and the capability and capacity of staff to influence it. We propose that context be considered to be dependent on ward- and hospital-level factors. Additionally, questions need to be considered about the unit of measurement of context in studies of knowledge implementation–is individual (micro), ward (meso) or hospital-level (macro) data most appropriate? The preliminary results also raise questions about how best to utilise this instrument in knowledge translation research.

Geert M. Rutten, Saskia Degen, Erik J. Hendriks, Jozé C. Braspenning, Janneke Harting, and Rob A. Oostendorp. Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit? Phys Ther 2010;90:1111-1122.

Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive. Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. Design This was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients. Methods Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses. Results Higher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005). Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses. Conclusions The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

Amir Qaseem, Vincenza Snow, Douglas K. Owens, Paul Shekelle, and for the Clinical Guidelines Committee of the American College of Physicians. The Development of Clinical Practice Guidelines and Guidance Statements of the American College of Physicians: Summary of Methods. Ann Intern Med 2010;153:194-199.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP's Guidelines Committee and the staff of the Clinical Programs and Quality of Care Department develop the clinical recommendations. The ACP develops 2 different types of clinical recommendations: clinical practice guidelines and clinical guidance statements. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading. All ACP clinical practice guidelines and clinical guidance statements, if not updated, are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Gunn JM, Palmer VJ, Dowrick CF, Herrman HE, Griffiths FE, Kokanovic R, Blashki GA, Hegarty KL, Johnson CL, Potiriadis M, May CR . Embedding effective depression care: using theory for primary care organisational and systems change. Implementation Science 2010;5:62

Background: Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. Methods: We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. Results: Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and  techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires  engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences. Conclusions: Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.

Baker Adrian; Young Katharine; Potter Jonathan; Madan Ira. A review of grading systems for evidence-based guidelines produced by medical specialties. Clinical Medicine, Journal of the Royal College of Physicians 2010;10(4): 358-363.

The development of evidence-based guidelines requires scrupulous attention to the method of critical appraisal. Many critical appraisal systems give `gold standard' status to randomised controlled trials (RCTs) due to their ability to limit bias. While guidelines with a prominent research base consisting of RCTs have been well served by such systems, specialist societies with research bases consisting of a wide range of study designs have been at a disadvantage, potentially leading to inappropriately low grades being given for recommendations. A review of the Scottish Intercollegiate Guidelines Network, the Grading of Recommendations Assessment, Development and Evaluation, the Graphic Appraisal Tool for Epidemiology and the National Service Framework for Long Term Conditions grading systems was therefore undertaken. A matrix was developed suggesting the optimum grading system for the type of guideline being developed or question being addressed by a specialist society.

Paul Glasziou, Iain Chalmers, Douglas G Altman, Hilda Bastian, Isabelle Boutron, Anne Brice, Gro Jamtvedt, Andrew Farmer, Davina Ghersi, Trish Groves, Carl Heneghan, Sophie Hill, Simon Lewin, Susan Michie, Rafael Perera, Valerie Pomeroy, Julie Tilson, Sasha Shepperd, John W Williams.Taking healthcare interventions from trial to practice. BMJ 2010; 341:c3852

The results of thousands of trials are never acted on because their published reports do not describe the interventions in enough detail. How can we improve the reporting?

Leykum LK, Parchman M, Pugh J, Lawrence V, Noel PH, McDaniel RR. The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure. Implementation Science 2010;5:66.

Background: Despite applications of models of care and organizational or system-level interventions to improve patient outcomes for chronic disease, consistent improvements have not been achieved. This may reflect a mismatch between the interventions and the nature of the settings in which they are attempted. The application of complex adaptive systems (CAS) framework to understand clinical systems and inform efforts to improve them may lead to more successful interventions. We performed a systematic review of interventions to improve outcomes of patients with congestive heart failure (CHF) to examine whether interventions consistent with CAS are more likely to be effective. We then examine differences between interventions that are most effective for improving outcomes for patients with CHF versus previously published data for type 2 diabetes to explore the potential impact of the nature of the disease on the types of interventions that are more likely to be effective. Methods: We conducted a systematic review of the literature between 1998 and 2008 of organizational interventions to improve care of patients with CHF. Two independent reviewers independently assessed studies that met inclusion criteria to determine whether each reported intervention reflected one or more CAS characteristics. The effectiveness of interventions was rated as either 0 (no effect), 0.5 (mixed effect), or 1.0 (effective) based on the type, number, and significance of reported outcomes. Fisher’s exact test was used to examine the association between CAS characteristics and intervention effectiveness. Specific CAS characteristics associated with intervention effectiveness for CHF were contrasted with previously published data for type 2 diabetes. Results and discussion: Forty-four studies describing 46 interventions met eligibility criteria. All interventions utilized at least one CAS characteristic, and 85% were either ‘mixed effect’ or ‘effective’ in terms of outcomes. The number of CAS characteristics present in each intervention was associated with effectiveness (p < 0.001), supporting the idea that interventions consistent with CAS are more likely to be effective. The individual CAS characteristics associated with CHF intervention effectiveness were learning, self-organization, and co-evolution, a finding different from our previously published analysis of interventions for diabetes. We suggest this difference may be related to the degree of uncertainty involved in caring for patients with diabetes versus CHF. Conclusion: These results suggest that for interventions to be effective, they must be consistent with the CAS nature of clinical systems. The difference in specific CAS characteristics associated with intervention effectiveness for CHF and diabetes suggests that interventions must also take into account attributes of the disease.

M Gillett, H M Dallosso, S Dixon, A Brennan, M E Carey, M J Campbell, S Heller, K Khunti, T C Skinner, M J Davies. Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis. BMJ 2010; 341:c4093

Objectives To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes. Design We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current “real world” costs of delivering the intervention estimated for a hypothetical primary care trust. Setting Primary care trusts in the United Kingdom. Participants Patients with newly diagnosed type 2 diabetes. Intervention A six hour structured group education programme delivered in the community by two professional healthcare educators. Main outcome measures Incremental costs and quality adjusted life years (QALYs) gained. Results On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is £209 (95% confidence interval −£704 to £1137; €251, −€844 to €1363; $326, −$1098 to $1773), the incremental gain in QALYs per person is 0.0392 (−0.0813 to 0.1786), and the mean incremental cost per QALY is £5387. Using “real world” intervention costs, the lifetime incremental cost of the DESMOND intervention is £82 (−£831 to £1010) and the mean incremental cost per QALY gained is £2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of £20 000 per QALY is 66% using trial based intervention costs and 70% using “real world” costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year. Conclusion Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.

Christopher E Clark, Lindsay F P Smith, Rod S Taylor, John L Campbell. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ 2010; 341:c3995.

Objective To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. Design Systematic review and meta-analysis. Data sources Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Study selection Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. Data extraction Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. Data synthesis Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference −8.2 mm Hg, 95% confidence interval −11.5 to −4.9), nurse prescribing showed greater reductions in blood pressure (systolic −8.9 mm Hg, −12.5 to −5.3 and diastolic −4.0 mm Hg, −5.3 to −2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic −4.8 mm Hg, 95% confidence interval −7.0 to −2.7 and diastolic −3.5 mm Hg, −4.5 to −2.5). Conclusions Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.

Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implementation Science 2010;5:69.

Background: Scoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O’Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, further clarifying and enhancing this framework will help support the consistency with which authors undertake and report scoping studies and may encourage researchers and clinicians to engage in this process. Discussion: We build upon our experiences conducting three scoping studies using the Arksey and O’Malley methodology to propose recommendations that clarify and enhance each stage of the framework. Recommendations include: clarifying and linking the purpose and research question (stage one); balancing feasibility with breadth and comprehensiveness of the scoping process (stage two); using an iterative team approach to selecting studies (stage three) and extracting data (stage four); incorporating a numerical summary and qualitative thematic analysis, reporting results, and considering the implications of study findings to policy, practice, or research (stage five); and incorporating consultation with stakeholders as a required knowledge translation component of scoping study methodology (stage six). Lastly, we propose additional considerations for scoping study methodology in order to support the advancement, application and relevance of scoping studies in health research. Summary: Specific recommendations to clarify and enhance this methodology are outlined for each stage of the Arksey and O’Malley framework. Continued debate and development about scoping study methodology will help to maximize the usefulness and rigor of scoping study findings within healthcare research and practice.

Wang W, Saldana L, Brown C, Chamberlain P. Factors that influenced county system leaders to implement an evidence-based program: A baseline survey within a randomized controlled trial. Implementation Science 2010;5:72.

Background: Despite the burgeoning number of well-validated interventions that have been shown in randomized trials to produce superior outcomes compared to usual services, it is estimated that only 10% of public systems deliver evidence-based mental health services. In California, for example, more than 15,000 children are placed in group homes or residential centers with some evidence of iatrogenic effects. The present study evaluates the willingness among county leaders of child public service systems to adopt a new evidence-based model, Multidimensional Treatment Foster Care, (MTFC), as a way to decrease the prevalence of out-of-home placements. Specifically, the study examines how county-level socio-demographic factors and child public service system leaders' perceptions of their county's organizational climate influence their decision of whether or not to consider adopting MTFC. Methods: Two levels were examined in this study: Stable and historical factors from 40 California counties gathered from public records including population size, number of entries into out-of-home care, financing of mental health services, and percent minority population; and system leaders' perceptions of their county's organizational climate and readiness for change measured via a web-based survey. The number of days-to-consent was the primary outcome variable defined as the duration of time between being notified of the opportunity to implement MTFC and the actual signing of a consent form indicating interest in considering implementation. Survival analysis methods were used to assess the predictors of this time-to-event measure. The present study is part of a larger randomized trial comparing two methods of implementation where counties are randomized to one of three time cohorts and two implementation conditions. Results: The number of entries into care was the primary predictor of days-to-consent. This variable was significantly correlated to county size. System leader's perceptions of positive climate and organizational readiness for change also contributed to but did not mediate or moderate the days-to-consent. Conclusions: System leaders' decision to consider implementing a new evidence-based model was influenced most by their objective need for the program and next by their perception of the county's organizational climate and motivation to change. These findings highlight the importance of understanding the fit between the needs of the systems or agencies and the potential for addressing those needs with the proposed new program.

Richard J Lilford, Peter J Chilton, Karla Hemming, Alan J Girling, Celia A Taylor, Paul Barach. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ 2010;341:c4413

The effect of many cost effective policy and service interventions cannot be detected at the level of the patient. This new framework could help improve the design (especially choice of primary end point) and interpretation of evaluative studies.

John P A Ioannidis, Fotini B Karassa. The need to consider the wider agenda in systematic reviews and meta-analyses: breadth, timing, and depth of the evidence.BMJ 2010; 341:c4875.

A.M. Knops, M.N. Storm-Versloot, A.P.M. Mank, D.T. Ubbink, H. Vermeulen, P.M.M. Bossuyt, and A. Goossens. Factors influencing long-term adherence to two previously implemented hospital guidelines. Int J Qual Health Care 2010;22(5): 421-429.

Objective and Setting After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence. Design and Participants A fluid balance guideline (FBG) and body temperature guideline (BTG) were developed and implemented in our hospital in 2000. Long-term adherence was determined retrospectively based on data from patient files. Focus groups were launched to explore nurses' perceptions of barriers and facilitators regarding long-term adherence. The predominant themes from the nurses' focus groups were posed to clinicians in questionnaires. Results Nurses involved in the FBG (overall adherence 100%) stated that adherence has immediate advantages in terms of safety and a gain in time. Nurses and oncologists acted unanimously which was thought to enhance adherence. On the other hand, opinions differed on the BTG within the nursing teams and medical staff (overall adherence 50%). Although the guideline discourages routine postoperative body temperature measurements, temperature should be measured according to the guideline in a considerable number of cases due to changes in patient characteristics since the year 2000. Therefore, adherence was judged to be rather complex. Conclusions To secure adherence to hospital guidelines after their successful implementation, guidelines should preferably be comprehensive in terms of being applicable to the majority of the patients in that particular setting and to the most common clinical situations. All healthcare professionals involved should be aware of its immediate benefits for themselves or to their patients.

Ya-Wen Chiu, Yi-Hao Weng, Heng-Lien Lo, Ya-Hui Shih, Chih-Cheng Hsu, and Ken N. Kuo. Impact of a nationwide outreach program on the diffusion of evidence-based practice in Taiwan. Int J Qual Health Care 2010;22(5):430-436.

Rationale To disseminate evidence-based practice (EBP) among hospital-based health professionals, since 2007 the National Health Research Institutes (NHRI) of Taiwan has run a complex outreach program that includes information resource support and promotional campaigns. Objectives The aim is to evaluate the impact of this outreach program on the diffusion of EBP. Setting Sixty-one regional hospitals in Taiwan. Design A cross-sectional, pre- and post-survey of a nationally representative sample of physicians and nurses was carried out in 2007 and 2009 to examine views related to EBP including changes in beliefs, attitudes, knowledge, skills, perceived barriers and behaviors. Results Physicians and nurses in the 2009 survey tended to have more knowledge and skill of EBP than their counterparts in the 2007 survey. They were less likely, however, to believe that EBP can improve patient care quality and to support the implementation of EBP. The prevalence of perceived barriers to EBP declined during the 2-year study period. In addition, physicians and nurses were more likely to access the online evidence retrieval databases according to the 2009 survey when compared with responses to the 2007 survey. Conclusions The knowledge of, skill in, and behavior regarding EBP have improved among physicians and nurses of regional hospitals in Taiwan after a promotion period of 2 years and they perceive fewer barriers to EBP. These data suggest that the multifaceted nationwide promotion program of the type conducted by NHRI succeeded in diffusion and implementation of EBP among professionals.

 
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