Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review

PubMed Central

Shanbhag, Deepti; Graham, Ian D; Harlos, Karen; Haynes, R. Brian; Gabizon, Itzhak; Connolly, Stuart J; Van Spall, Harriette Gillian Christine

2018-01-01

Background The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. Methods We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. Results We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. Conclusion Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. PMID:29511005

Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review.

PubMed

Shanbhag, Deepti; Graham, Ian D; Harlos, Karen; Haynes, R Brian; Gabizon, Itzhak; Connolly, Stuart J; Van Spall, Harriette Gillian Christine

2018-03-06

The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Attenuating the Systemic Inflammatory Response to Adult Cardiopulmonary Bypass: A Critical Review of the Evidence Base

PubMed Central

Landis, R. Clive; Brown, Jeremiah R.; Fitzgerald, David; Likosky, Donald S.; Shore-Lesserson, Linda; Baker, Robert A.; Hammon, John W.

2014-01-01

Abstract: A wide range of pharmacological, surgical, and mechanical pump approaches have been studied to attenuate the systemic inflammatory response to cardiopulmonary bypass, yet no systematically based review exists to cover the scope of anti-inflammatory interventions deployed. We therefore conducted an evidence-based review to capture “self-identified” anti-inflammatory interventions among adult cardiopulmonary bypass procedures. To be included, trials had to measure at least one inflammatory mediator and one clinical outcome, specified in the “Outcomes 2010” consensus statement. Ninety-eight papers satisfied inclusion criteria and formed the basis of the review. The review identified 33 different interventions and approaches to attenuate the systemic inflammatory response. However, only a minority of papers (35 of 98 [35.7%]) demonstrated any clinical improvement to one or more of the predefined outcome measures (most frequently myocardial protection or length of intensive care unit stay). No single intervention was supported by strong level A evidence (multiple randomized controlled trials [RCTs] or meta-analysis) for clinical benefit. Interventions at level A evidence included off-pump surgery, minimized circuits, biocompatible circuit coatings, leukocyte filtration, complement C5 inhibition, preoperative aspirin, and corticosteroid prophylaxis. Interventions at level B evidence (single RCT) for minimizing inflammation included nitric oxide donors, C1 esterase inhibition, neutrophil elastase inhibition, propofol, propionyl-L-carnitine, and intensive insulin therapy. A secondary analysis revealed that suppression of at least one inflammatory marker was necessary but not sufficient to confer clinical benefit. The most effective interventions were those that targeted multiple inflammatory pathways. These observations are consistent with a “multiple hit” hypothesis, whereby clinically effective suppression of the systemic inflammatory response requires hitting multiple inflammatory targets simultaneously. Further research is warranted to evaluate if combinations of interventions that target multiple inflammatory pathways are capable of synergistically reducing inflammation and improving outcomes after cardiopulmonary bypass. PMID:26357785

A group randomized trial using an appointment system to improve adherence to ART at reproductive and child health clinics implementing Option B+ in Tanzania

PubMed Central

Liana, Jafary; Kajoka, Mwikemo Deborah; Valimba, Richard; Kimatta, Suleiman; Dillip, Angel; Vialle-Valentin, Catherine; Embrey, Martha; Lieber, Rachel; Johnson, Keith

2017-01-01

Introduction In October 2013, Tanzania adopted Option B+ under which HIV-positive pregnant women are initiated on antiretroviral therapy in reproductive and child health clinics at diagnosis. Studies have shown that adherence and retention to antiretroviral treatment can be problematic. Methods We implemented a group randomized controlled trial in 24 reproductive and child health clinics in eight districts in Mbeya region. The trial tested the impact of implementing paper-based appointment tracking and community outreach systems on the rate of missed appointments and number of days covered by dispensed antiretroviral medications among women previously established on antiretroviral therapy. We used interrupted time series analysis to assess study outcomes. Clinic staff and patients in intervention clinics were aware of the intervention because of change in clinic procedures; data collectors knew the study group assignment. Results Three months pre-intervention, we identified 1924 and 1226 patients established on antiretroviral therapy for six months or more in intervention and control clinics, respectively, of whom 83.4% and 86.9% had one or more post-intervention visits. The unadjusted rate of missed visits declined from 36.5% to 34.4% in intervention clinics and increased from 38.9% to 45.5% in control clinics following the intervention. Interrupted time series analyses demonstrated a net decrease of 13.7% (95% CI [-15.4,-12.1]) for missed visits at six months post-intervention. Similar differential changes were observed for visits missed by 3, 7, 15, or 60 days. Conclusion Appointment-tracking and community outreach significantly improved appointment-keeping for women on antiretroviral therapy. The facility staff controlled their workload better, identified missing patients rapidly, and worked with existing community organizations. There is now enough evidence to scale up this approach to all antiretroviral therapy and Option B+ reproductive and child health clinics in Tanzania as well as to evaluate the intervention in medical clinics that treat other chronic health conditions. Trial registration Registry for International Development Impact Evaluations ID-55310280d8757 PMID:28957381

Evaluation of the implementation of a clinical pharmacy service on an acute internal medicine ward in Italy.

PubMed

Lombardi, Nicola; Wei, Li; Ghaleb, Maisoon; Pasut, Enrico; Leschiutta, Silvia; Rossi, Paolo; Troncon, Maria Grazia

2018-04-10

Successful implementation of clinical pharmacy services is associated with improvement of appropriateness of prescribing. Both high clinical significance of pharmacist interventions and their high acceptance rate mean that potential harm to patients could be avoided. Evidence shows that low acceptance rate of pharmacist interventions can be associated with lack of communication between pharmacists and the rest of the healthcare team. The objective of this study was to evaluate the effect of a structured communication strategy on acceptance rate of interventions made by a clinical pharmacist implementing a ward-based clinical pharmacy service targeting elderly patients at high risk of drug-related problems. Characteristics of interventions made to improve appropriateness of prescribing, their clinical significance and intervention acceptance rate by doctors were recorded. A clinical pharmacy intervention study was conducted between September 2013 and December 2013 in an internal medicine ward of a teaching hospital. A trained clinical pharmacist provided pharmaceutical care to 94 patients aged over 70 years. The clinical pharmacist used the following communication and marketing tools to implement the service described: Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis; Specific, Measurable, Achievable, Realistic and Timely (SMART) goals; Awareness, Interest, Desire, Action (AIDA) model. A total of 740 interventions were made by the clinical pharmacist. The most common drug classes involved in interventions were: antibacterials for systemic use (11.1%) and anti-parkinson drugs (10.8%). The main drug-related problem categories triggering interventions were: no specific problem (15.9%) and prescription writing error (12.0%). A total of 93.2% of interventions were fully accepted by physicians. After assessment by an external panel 63.2% of interventions (96 interventions/ per month) were considered of moderate clinical significance and 23.4% (36 interventions/ per month) of major clinical significance. The most frequent interventions were to educate a healthcare professional (20.4%) and change dose (16.1%). To our knowledge this is the first study evaluating the effect of a structured communication strategy on acceptance rate of pharmacist interventions. Pharmaceutical care delivered by the clinical pharmacist is likely to have had beneficial outcomes. Clinical pharmacy services like the one described should be implemented widely to increase patient safety.

PLUS: open-source toolkit for ultrasound-guided intervention systems.

PubMed

Lasso, Andras; Heffter, Tamas; Rankin, Adam; Pinter, Csaba; Ungi, Tamas; Fichtinger, Gabor

2014-10-01

A variety of advanced image analysis methods have been under the development for ultrasound-guided interventions. Unfortunately, the transition from an image analysis algorithm to clinical feasibility trials as part of an intervention system requires integration of many components, such as imaging and tracking devices, data processing algorithms, and visualization software. The objective of our paper is to provide a freely available open-source software platform-PLUS: Public software Library for Ultrasound-to facilitate rapid prototyping of ultrasound-guided intervention systems for translational clinical research. PLUS provides a variety of methods for interventional tool pose and ultrasound image acquisition from a wide range of tracking and imaging devices, spatial and temporal calibration, volume reconstruction, simulated image generation, and recording and live streaming of the acquired data. This paper introduces PLUS, explains its functionality and architecture, and presents typical uses and performance in ultrasound-guided intervention systems. PLUS fulfills the essential requirements for the development of ultrasound-guided intervention systems and it aspires to become a widely used translational research prototyping platform. PLUS is freely available as open source software under BSD license and can be downloaded from http://www.plustoolkit.org.

Counselors, Students of Color, and College: Student-Centered and Systemic Multicultural Interventions.

ERIC Educational Resources Information Center

Gary, Juneau Mahan

Student demographics on campuses increasingly reflect diversity. A counselor's ability to help this emerging campus population requires the use of multicultural interventions that affect the student and the system. Counselors must redefine the process of clinical assessment and intervention to include ethnocultural factors and they must intervene…

Post-procedural Care in Interventional Radiology: What Every Interventional Radiologist Should Know-Part II: Catheter Care and Management of Common Systemic Post-procedural Complications.

PubMed

Taslakian, Bedros; Sridhar, Divya

2017-09-01

Interventional radiology (IR) has evolved into a full-fledged clinical specialty with attendant comprehensive patient care responsibilities. Providing excellent and thorough clinical care is as essential to the practice of IR as achieving technical success in procedures. Basic clinical skills that every interventional radiologist should learn include routine management of percutaneously inserted drainage and vascular catheters and rapid effective management of common systemic post-procedural complications. A structured approach to post-procedural care, including routine follow-up and early identification and management of complications, facilitates efficient and thorough management with an emphasis on quality and patient safety. The aim of this second part, in conjunction with part 1, is to complete the comprehensive review of post-procedural care in patients undergoing interventional radiology procedures. We discuss common problems encountered after insertion of drainage and vascular catheters and describe effective methods of troubleshooting these problems. Commonly encountered systemic complications in IR are described, and ways for immediate identification and management of these complications are provided.

Algorithmic Approach With Clinical Pathology Consultation Improves Access to Specialty Care for Patients With Systemic Lupus Erythematosus.

PubMed

Chen, Lei; Welsh, Kerry J; Chang, Brian; Kidd, Laura; Kott, Marylee; Zare, Mohammad; Carroll, Kelley; Nguyen, Andy; Wahed, Amer; Tholpady, Ashok; Pung, Norin; McKee, Donna; Risin, Semyon A; Hunter, Robert L

2016-09-01

Harris Health System (HHS) is a safety net system providing health care to the underserved of Harris County, Texas. There was a 6-month waiting period for a rheumatologist consult for patients with suspected systemic lupus erythematosus (SLE). The objective of the intervention was to improve access to specialty care. An algorithmic approach to testing for SLE was implemented initially through the HHS referral center. The algorithm was further offered as a "one-click" order for physicians, with automated reflex testing, interpretation, and case triaging by clinical pathology. Data review revealed that prior to the intervention, 80% of patients did not have complete laboratory workups available at the first rheumatology visit. Implementation of algorithmic testing and triaging of referrals by pathologists resulted in decreasing the waiting time for a rheumatologist by 50%. Clinical pathology intervention and case triaging can improve access to care in a county health care system. © American Society for Clinical Pathology, 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments.

PubMed

Shin, Joon-Ho; Ryu, Hokyoung; Jang, Seong Ho

2014-03-06

Virtual reality (VR) is not commonly used in clinical rehabilitation, and commercial VR gaming systems may have mixed effects in patients with stroke. Therefore, we developed RehabMaster™, a task-specific interactive game-based VR system for post-stroke rehabilitation of the upper extremities, and assessed its usability and clinical efficacy. A participatory design and usability tests were carried out for development of RehabMaster with representative user groups. Two clinical trials were then performed. The first was an observational study in which seven patients with chronic stroke received 30 minutes of RehabMaster intervention per day for two weeks. The second was a randomised controlled trial of 16 patients with acute or subacute stroke who received 10 sessions of conventional occupational therapy only (OT-only group) or conventional occupational therapy plus 20 minutes of RehabMaster intervention (RehabMaster + OT group). The Fugl-Meyer Assessment score (FMA), modified Barthel Index (MBI), adverse effects, and drop-out rate were recorded. The requirements of a VR system for stroke rehabilitation were established and incorporated into RehabMaster. The reported advantages from the usability tests were improved attention, the immersive flow experience, and individualised intervention. The first clinical trial showed that the RehabMaster intervention improved the FMA (P = .03) and MBI (P = .04) across evaluation times. The second trial revealed that the addition of RehabMaster intervention tended to enhance the improvement in the FMA (P = .07) but did not affect the improvement in the MBI. One patient with chronic stroke left the trial, and no adverse effects were reported. The RehabMaster is a feasible and safe VR system for enhancing upper extremity function in patients with stroke.

A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments

PubMed Central

2014-01-01

Background Virtual reality (VR) is not commonly used in clinical rehabilitation, and commercial VR gaming systems may have mixed effects in patients with stroke. Therefore, we developed RehabMaster™, a task-specific interactive game-based VR system for post-stroke rehabilitation of the upper extremities, and assessed its usability and clinical efficacy. Methods A participatory design and usability tests were carried out for development of RehabMaster with representative user groups. Two clinical trials were then performed. The first was an observational study in which seven patients with chronic stroke received 30 minutes of RehabMaster intervention per day for two weeks. The second was a randomised controlled trial of 16 patients with acute or subacute stroke who received 10 sessions of conventional occupational therapy only (OT-only group) or conventional occupational therapy plus 20 minutes of RehabMaster intervention (RehabMaster + OT group). The Fugl-Meyer Assessment score (FMA), modified Barthel Index (MBI), adverse effects, and drop-out rate were recorded. Results The requirements of a VR system for stroke rehabilitation were established and incorporated into RehabMaster. The reported advantages from the usability tests were improved attention, the immersive flow experience, and individualised intervention. The first clinical trial showed that the RehabMaster intervention improved the FMA (P = .03) and MBI (P = .04) across evaluation times. The second trial revealed that the addition of RehabMaster intervention tended to enhance the improvement in the FMA (P = .07) but did not affect the improvement in the MBI. One patient with chronic stroke left the trial, and no adverse effects were reported. Conclusions The RehabMaster is a feasible and safe VR system for enhancing upper extremity function in patients with stroke. PMID:24597650

Cost-benefit of a clinical services integrated with a decentralized unit dose system.

PubMed

Warrian, K; Irvine-Meek, J

1988-06-01

Clinical pharmacy services are believed to be beneficial to patient care and to have the potential to reduce drug costs. This study was designed to apply cost-benefit analysis techniques to selected clinical pharmacy services provided by staff pharmacists assigned to a mobile decentralized unit-dose drug distribution system. Pharmacists' interventions were identified and recorded by the pharmacists and the investigator over an eight-week period. Interventions, to which a monetary value could be assigned, included non-formulary drug use, drug regimen adjustments, and the duration of drug therapy. A total of 543 interventions were recorded or observed. Of these, 174 (32 percent) fit the criteria for inclusion in the study. Those interventions accepted by physicians (87 percent) were assigned a dollar value and tabulated. Costs to provide the service were the pharmacists' salaries. Benefit to cost ratios of 1.08 and 1.59 demonstrated that the benefits accrued from selected clinical pharmacy services exceeded the costs to the hospital.

California's digital divide: clinical information systems for the haves and have-nots.

PubMed

Miller, Robert H; D'Amato, Katherine; Oliva, Nancy; West, Christopher E; Adelson, Joel W

2009-01-01

Strong barriers prevent the financing of clinical information systems (CIS) in health care delivery system organizations in market segments serving disadvantaged patients. These segments include community health centers, public hospitals, unaffiliated rural hospitals, and some Medicaid-oriented solo and small-group medical practices. Policy interventions such as loans, grants, pay-for-performance and other reimbursement changes, and support services assistance will help lower these barriers. Without intervention, progress will be slow and worsen health care disparities between the advantaged and disadvantaged populations.

Multidisciplinary COPD disease management program: impact on clinical outcomes.

PubMed

Morganroth, Melvin; Pape, Ginger; Rozenfeld, Yelena; Heffner, John E

2016-01-01

We hypothesized performance improvement interventions would improve COPD guideline-recommended care and decrease COPD exacerbations in primary care clinic practices. We initiated a performance improvement project in 12 clinics to improve COPD outcomes incorporating physician education, case management, web-based decision support (CareManager(TM)), and performance feedback. We collected baseline and one-year follow up data on 242 patients who had COPD with acute exacerbations. We analyzed data by two methods. First, the 12 clinics were cluster randomized to 4 intervention (117 patients) and 8 control (125 patients) clinics which all had access to CareManager(TM) but only intervention clinic physicians received case management, academic detailing, and decision support assistance. Exacerbation rates and guideline adherence were compared. Second, data from all 12 clinics were pooled in a quasi-experimental design comparing baseline and post-implementation of CareManager(TM) to determine the value of system-wide performance improvement during the study period. In the randomized analysis, baseline demographics were similar. No differences (p = 0.79) occurred in exacerbation rates between intervention and control clinics although both groups had decreased numbers of exacerbations from baseline to follow up (p < 0.05). The pooled data from all 12 clinics demonstrated a reduction (p < 0.05) in mean exacerbations/patient from 2.3 (CI 2.0-2.6) during baseline to 1.4 (CI 1.1-1.7) at one-year follow up. Emergency department visits and hospitalizations/patient decreased (p = 0.003). Patients naïve at study start to depression screening, pneumococcal vaccination, inhaled control medications or smoking cessation had fewer (p < 0.05) exacerbations after these interventions. We observed no difference in exacerbation rates between clinics receiving case management, academic detailing, and ongoing assistance with decision support and controls. Implementation of a web-based disease management system (CareManager(TM)) along with health system-wide COPD performance improvement efforts was associated with fewer COPD exacerbations and increased adherence to guideline recommendations.

The effects of expanding outpatient and inpatient evaluation and management services in a pediatric interventional radiology practice.

PubMed

Edalat, Faramarz; Lindquester, Will S; Gill, Anne E; Simoneaux, Stephen F; Gaines, Jennifer; Hawkins, C Matthew

2017-03-01

Despite a continuing emphasis on evaluation and management clinical services in adult interventional radiology (IR) practice, the peer-reviewed literature addressing these services - and their potential economic benefits - is lacking in pediatric IR practice. To measure the effects of expanding evaluation and management (E&M) services through the establishment of a dedicated pediatric interventional radiology outpatient clinic and inpatient E&M reporting system. We collected and analyzed E&M current procedural terminology (CPT) codes from all patients seen in a pediatric interventional radiology outpatient clinic between November 2014 and August 2015. We also calculated the number of new patients seen in the clinic who had a subsequent procedure (procedural conversion rate). For comparison, we used historical data comprising pediatric patients seen in a general interventional radiology (IR) clinic for the 2 years immediately prior. An inpatient E&M reporting system was implemented and all inpatient E&M (and subsequent procedural) services between July 2015 and September 2015 were collected and analyzed. We estimated revenue for both outpatient and inpatient services using the Medicare Physician Fee Schedule global non-facility price as a surrogate. Following inception of a pediatric IR clinic, the number of new outpatients (5.5/month; +112%), procedural conversion rate (74.5%; +19%), estimated E&M revenue (+158%), and estimated procedural revenue from new outpatients (+228%) all increased. Following implementation of an inpatient clinic reporting system, there were 8.3 consults and 7.3 subsequent hospital encounters per month, with a procedural conversion rate of 88%. Growth was observed in all meaningful metrics following expansion of outpatient and inpatient pediatric IR E&M services.

Application of systems thinking: 12-month postintervention evaluation of a complex health system intervention in Zambia: the case of the BHOMA.

PubMed

Mutale, Wilbroad; Ayles, Helen; Bond, Virginia; Chintu, Namwinga; Chilengi, Roma; Mwanamwenge, Margaret Tembo; Taylor, Angela; Spicer, Neil; Balabanova, Dina

2017-04-01

Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences. © 2015 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

Interventional robotic systems: Applications and technology state-of-the-art

PubMed Central

CLEARY, KEVIN; MELZER, ANDREAS; WATSON, VANCE; KRONREIF, GERNOT; STOIANOVICI, DAN

2011-01-01

Many different robotic systems have been developed for invasive medical procedures. In this article we will focus on robotic systems for image-guided interventions such as biopsy of suspicious lesions, interstitial tumor treatment, or needle placement for spinal blocks and neurolysis. Medical robotics is a young and evolving field and the ultimate role of these systems has yet to be determined. This paper presents four interventional robotics systems designed to work with MRI, CT, fluoroscopy, and ultrasound imaging devices. The details of each system are given along with any phantom, animal, or human trials. The systems include the AcuBot for active needle insertion under CT or fluoroscopy, the B-Rob systems for needle placement using CT or ultrasound, the INNOMOTION for MRI and CT interventions, and the MRBot for MRI procedures. Following these descriptions, the technology issues of image compatibility, registration, patient movement and respiration, force feedback, and control mode are briefly discussed. It is our belief that robotic systems will be an important part of future interventions, but more research and clinical trials are needed. The possibility of performing new clinical procedures that the human cannot achieve remains an ultimate goal for medical robotics. Engineers and physicians should work together to create and validate these systems for the benefits of patients everywhere. PMID:16754193

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

PubMed

Wu, Robert C; Lo, Vivian; Morra, Dante; Wong, Brian M; Sargeant, Robert; Locke, Ken; Cavalcanti, Rodrigo; Quan, Sherman D; Rossos, Peter; Tran, Kim; Cheung, Mark

2013-01-01

Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness. To describe the effects of different communication interventions and their problems. Prospective observational case study using a mixed methods approach of quantitative and qualitative methods. General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals. Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards. Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010. We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories. Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.

The effect of systematic clinical interventions with cigarette smokers on quit status and the rates of smoking-related primary care office visits.

PubMed

Land, Thomas G; Rigotti, Nancy A; Levy, Douglas E; Schilling, Thad; Warner, Donna; Li, Wenjun

2012-01-01

The United States Public Health Service (USPHS) Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data. Data on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites. An operational definition of "systems change" was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<.01). On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI: 0.1%-4.6%) per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05, 95% CI: 0.5%-8.1%). There was no change in the likelihood of an office visit for smoking-related diagnoses following systems change among non-smokers. The clinical practice data from HVMA suggest that a systems approach can lead to significant reductions in smoking prevalence and the rate of office visits for smoking-related diseases. Most comprehensive tobacco intervention strategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core tobacco measures are widely adopted.

The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking-Related Primary Care Office Visits

PubMed Central

Land, Thomas G.; Rigotti, Nancy A.; Levy, Douglas E.; Schilling, Thad; Warner, Donna; Li, Wenjun

2012-01-01

Background The United States Public Health Service (USPHS) Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data. Methods and Findings Data on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites. An operational definition of “systems change” was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<.01). On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI: 0.1%–4.6%) per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05, 95% CI: 0.5%–8.1%). There was no change in the likelihood of an office visit for smoking-related diagnoses following systems change among non-smokers. Conclusions The clinical practice data from HVMA suggest that a systems approach can lead to significant reductions in smoking prevalence and the rate of office visits for smoking-related diseases. Most comprehensive tobacco intervention strategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core tobacco measures are widely adopted. PMID:22911834

Nursing Classification Systems

PubMed Central

Henry, Suzanne Bakken; Mead, Charles N.

1997-01-01

Abstract Our premise is that from the perspective of maximum flexibility of data usage by computer-based record (CPR) systems, existing nursing classification systems are necessary, but not sufficient, for representing important aspects of “what nurses do.” In particular, we have focused our attention on those classification systems that represent nurses' clinical activities through the abstraction of activities into categories of nursing interventions. In this theoretical paper, we argue that taxonomic, combinatorial vocabularies capable of coding atomic-level nursing activities are required to effectively capture in a reproducible and reversible manner the clinical decisions and actions of nurses, and that, without such vocabularies and associated grammars, potentially important clinical process data is lost during the encoding process. Existing nursing intervention classification systems do not fulfill these criteria. As background to our argument, we first present an overview of the content, methods, and evaluation criteria used in previous studies whose focus has been to evaluate the effectiveness of existing coding and classification systems. Next, using the Ingenerf typology of taxonomic vocabularies, we categorize the formal type and structure of three existing nursing intervention classification systems—Nursing Interventions Classification, Omaha System, and Home Health Care Classification. Third, we use records from home care patients to show examples of lossy data transformation, the loss of potentially significant atomic data, resulting from encoding using each of the three systems. Last, we provide an example of the application of a formal representation methodology (conceptual graphs) which we believe could be used as a model to build the required combinatorial, taxonomic vocabulary for representing nursing interventions. PMID:9147341

An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases.

PubMed

Dietz, William H; Solomon, Loel S; Pronk, Nico; Ziegenhorn, Sarah K; Standish, Marion; Longjohn, Matt M; Fukuzawa, David D; Eneli, Ihuoma U; Loy, Lisel; Muth, Natalie D; Sanchez, Eduardo J; Bogard, Jenny; Bradley, Don W

2015-09-01

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here. Project HOPE—The People-to-People Health Foundation, Inc.

An analysis of registered clinical trials in otolaryngology from 2007 to 2010: ClinicalTrials.gov.

PubMed

Witsell, David L; Schulz, Kristine A; Lee, Walter T; Chiswell, Karen

2013-11-01

To describe the conditions studied, interventions used, study characteristics, and funding sources of otolaryngology clinical trials from the ClinicalTrials.gov database; compare this otolaryngology cohort of interventional studies to clinical visits in a health care system; and assess agreement between clinical trials and clinical activity. Database analysis. Trial registration data downloaded from ClinicalTrials.gov and administrative data from the Duke University Medical Center from October 1, 2007 to September 27, 2010. Data extraction from ClinicalTrials.gov was done using MeSH and non-MeSH disease condition terms. Studies were subcategorized to create the following groupings for descriptive analysis: ear, nose, allergy, voice, sleep, head and neck cancer, thyroid, and throat. Duke Health System visits were queried by using selected ICD-9 codes for otolaryngology and non-otolaryngology providers. Visits were grouped similarly to ClinicalTrials.gov for further analysis. Chi-square tests were used to explore differences between groups. A total of 1115 of 40,970 registered interventional trials were assigned to otolaryngology. Head and neck cancer trials predominated. Study models most frequently incorporated parallel design (54.6%), 2 study groups (46.6%), and randomization (69.1%). Phase 2 or 3 studies constituted 46.4% of the cohort. Comparison of the ClinicalTrials.gov database with administrative health system visit data by disease condition showed discordance between national research activity and clinical visit volume for patients with otolaryngology complaints. Analysis of otolaryngology-related clinical research as listed in ClinicalTrials.gov can inform patients, physicians, and policy makers about research focus areas. The relative burden of otolaryngology-associated conditions in our tertiary health system exceeds research activity within the field.

Reducing Clinical Inertia in Hypertension Treatment: a Pragmatic Randomized Controlled Trial

PubMed Central

Huebschmann, Amy G.; Mizrahi, Trina; Soenksen, Alyssa; Beaty, Brenda L.; Denberg, Thomas D.

2012-01-01

Clinical inertia is a major contributor to poor blood pressure (BP) control. We tested the effectiveness of an intervention targeting physician, patient, and office system factors with regard to outcomes of clinical inertia and BP control. We randomized 591 adult primary care patients with elevated BP (mean systolic BP ≥140 or mean diastolic BP ≥90 mm Hg) to intervention or usual care. An outreach coordinator raised patient and provider awareness of unmet BP goals, arranged BP-focused primary care clinic visits, and furnished providers with treatment decision support. The intervention reduced clinical inertia (−29% vs. −11%, p=0.001). Nonetheless, ΔBP did not differ between intervention and usual care (−10.1/−4.1 vs. −9.1/−4.5 mm Hg, p = 0.50 and 0.71 for systolic and diastolic BP, respectively). Future primary care-focused interventions might benefit from the use of specific medication titration protocols, treatment adherence support, and more sustained patient follow-up visits. PMID:22533659

Development and preliminary evaluation of an ultrasonic motor actuated needle guide for 3T MRI-guided transperineal prostate interventions

NASA Astrophysics Data System (ADS)

Song, Sang-Eun; Tokuda, Junichi; Tuncali, Kemal; Tempany, Clare; Hata, Nobuhiko

2012-02-01

Image guided prostate interventions have been accelerated by Magnetic Resonance Imaging (MRI) and robotic technologies in the past few years. However, transrectal ultrasound (TRUS) guided procedure still remains as vast majority in clinical practice due to engineering and clinical complexity of the MRI-guided robotic interventions. Subsequently, great advantages and increasing availability of MRI have not been utilized at its maximum capacity in clinic. To benefit patients from the advantages of MRI, we developed an MRI-compatible motorized needle guide device "Smart Template" that resembles a conventional prostate template to perform MRI-guided prostate interventions with minimal changes in the clinical procedure. The requirements and specifications of the Smart Template were identified from our latest MRI-guided intervention system that has been clinically used in manual mode for prostate biopsy. Smart Template consists of vertical and horizontal crossbars that are driven by two ultrasonic motors via timing-belt and mitergear transmissions. Navigation software that controls the crossbar position to provide needle insertion positions was also developed. The software can be operated independently or interactively with an open-source navigation software, 3D Slicer, that has been developed for prostate intervention. As preliminary evaluation, MRI distortion and SNR test were conducted. Significant MRI distortion was found close to the threaded brass alloy components of the template. However, the affected volume was limited outside the clinical region of interest. SNR values over routine MRI scan sequences for prostate biopsy indicated insignificant image degradation during the presence of the robotic system and actuation of the ultrasonic motors.

The search for relevant outcome measures for cost-utility analysis of systemic family interventions in adolescents with substance use disorder and delinquent behavior: a systematic literature review.

PubMed

Schawo, S; Bouwmans, C; van der Schee, E; Hendriks, V; Brouwer, W; Hakkaart, L

2017-09-19

Systemic family interventions have shown to be effective in adolescents with substance use disorder and delinquent behavior. The interventions target interactions between the adolescent and involved systems (i.e. youth, family, peers, neighbors, school, work, and society). Next to effectiveness considerations, economic aspects have gained attention. However, conventional generic quality of life measures used in health economic evaluations may not be able to capture the broad effects of systemic interventions. This study aims to identify existing outcome measures, which capture the broad effects of systemic family interventions, and allow use in a health economic framework. We based our systematic review on clinical studies in the field. Our goal was to identify effectiveness studies of psychosocial interventions for adolescents with substance use disorder and delinquent behavior and to distill the instruments used in these studies to measure effects. Searched databases were PubMed, Education Resource Information Center (ERIC), Cochrane and Psychnet (PsycBOOKSc, PsycCRITIQUES, print). Identified instruments were ranked according to the number of systems covered (comprehensiveness). In addition, their use for health economic analyses was evaluated according to suitability characteristics such as brevity, accessibility, psychometric properties, etc. One thousand three hundred seventy-eight articles were found and screened for eligibility. Eighty articles were selected, 8 instruments were identified covering 5 or more systems. The systematic review identified instruments from the clinical field suitable to evaluate systemic family interventions in a health economic framework. None of them had preference-weights available. Hence, a next step could be to attach preference-weights to one of the identified instruments to allow health economic evaluations of systemic family interventions.

Using Theater to Teach Clinical Empathy: A Pilot Study

PubMed Central

Leong, David; Anderson, Aaron; Wenzel, Richard P.

2007-01-01

Background Clinical empathy, a critical skill for the doctor–patient relationship, is infrequently taught in graduate medical education. No study has tested if clinical empathy can be taught effectively. Objective To assess whether medicine residents can learn clinical empathy techniques from theater professors. Design A controlled trial of a clinical empathy curriculum taught and assessed by 4 theater professors. Setting Virginia Commonwealth University, Richmond, Virginia, a large urban university and health system. Participants Twenty Internal Medicine residents: 14 in the intervention group, 6 in the control group. Intervention Six hours of classroom instruction and workshop time with professors of theater. Measurements Scores derived from an instrument with 6 subscores designed to measure empathy in real-time patient encounters. Baseline comparisons were made using two-sample T tests. A mixed-effects analysis of variance model was applied to test for significance between the control and intervention groups. Results The intervention group demonstrated significant improvement (p ≤ .011) across all 6 subscores between pre-intervention and post-intervention observations. Compared to the control group, the intervention group had better posttest scores in 5 of 6 subscores (p ≤ .01). Limitations The study was neither randomized nor blinded. Conclusions Collaborative efforts between the departments of theater and medicine are effective in teaching clinical empathy techniques. PMID:17486385

Information Technology-Based Interventions to Improve Drug-Drug Interaction Outcomes: A Systematic Review on Features and Effects.

PubMed

Nabovati, Ehsan; Vakili-Arki, Hasan; Taherzadeh, Zhila; Saberi, Mohammad Reza; Medlock, Stephanie; Abu-Hanna, Ameen; Eslami, Saeid

2017-01-01

The purpose of this systematic review was to identify features and effects of information technology (IT)-based interventions on outcomes related to drug-drug interactions (DDI outcomes). A literature search was conducted in Medline, EMBASE, and the Cochrane Library for published English-language studies. Studies were included if a main outcome was related to DDIs, the intervention involved an IT-based system, and the study design was experimental or observational with controls. Study characteristics, including features and effects of IT-based interventions, were extracted. Nineteen studies comprising five randomized controlled trials (RCT), five non-randomized controlled trials (NRCT) and nine observational studies with controls (OWC) were included. Sixty-four percent of prescriber-directed interventions, and all non-prescriber interventions, were effective. Each of the following characteristics corresponded to groups of studies of which a majority were effective: automatic provision of recommendations within the providers' workflow, intervention at the time of decision-making, integration into other systems, and requiring the reason for not following the recommendations. Only two studies measured clinical outcomes: an RCT that showed no significant improvement and an OWC that showed improvement, but did not statistically assess the effect. Most studies that measured surrogate outcomes (e.g. potential DDIs) and other outcomes (e.g. adherence to alerts) showed improvements. IT-based interventions improve surrogate clinical outcomes and adherence to DDI alerts. However, there is lack of robust evidence about their effectiveness on clinical outcomes. It is recommended that researchers consider the identified features of effective interventions in the design of interventions and evaluate the effectiveness on DDI outcomes, particularly clinical outcomes.

A navigation system for percutaneous needle interventions based on PET/CT images: design, workflow and error analysis of soft tissue and bone punctures.

PubMed

Oliveira-Santos, Thiago; Klaeser, Bernd; Weitzel, Thilo; Krause, Thomas; Nolte, Lutz-Peter; Peterhans, Matthias; Weber, Stefan

2011-01-01

Percutaneous needle intervention based on PET/CT images is effective, but exposes the patient to unnecessary radiation due to the increased number of CT scans required. Computer assisted intervention can reduce the number of scans, but requires handling, matching and visualization of two different datasets. While one dataset is used for target definition according to metabolism, the other is used for instrument guidance according to anatomical structures. No navigation systems capable of handling such data and performing PET/CT image-based procedures while following clinically approved protocols for oncologic percutaneous interventions are available. The need for such systems is emphasized in scenarios where the target can be located in different types of tissue such as bone and soft tissue. These two tissues require different clinical protocols for puncturing and may therefore give rise to different problems during the navigated intervention. Studies comparing the performance of navigated needle interventions targeting lesions located in these two types of tissue are not often found in the literature. Hence, this paper presents an optical navigation system for percutaneous needle interventions based on PET/CT images. The system provides viewers for guiding the physician to the target with real-time visualization of PET/CT datasets, and is able to handle targets located in both bone and soft tissue. The navigation system and the required clinical workflow were designed taking into consideration clinical protocols and requirements, and the system is thus operable by a single person, even during transition to the sterile phase. Both the system and the workflow were evaluated in an initial set of experiments simulating 41 lesions (23 located in bone tissue and 18 in soft tissue) in swine cadavers. We also measured and decomposed the overall system error into distinct error sources, which allowed for the identification of particularities involved in the process as well as highlighting the differences between bone and soft tissue punctures. An overall average error of 4.23 mm and 3.07 mm for bone and soft tissue punctures, respectively, demonstrated the feasibility of using this system for such interventions. The proposed system workflow was shown to be effective in separating the preparation from the sterile phase, as well as in keeping the system manageable by a single operator. Among the distinct sources of error, the user error based on the system accuracy (defined as the distance from the planned target to the actual needle tip) appeared to be the most significant. Bone punctures showed higher user error, whereas soft tissue punctures showed higher tissue deformation error.

Closing the quality gap: revisiting the state of the science (vol. 4: medication adherence interventions: comparative effectiveness).

PubMed

Viswanathan, Meera; Golin, Carol E; Jones, Christine D; Ashok, Mahima; Blalock, Susan; Wines, Roberta C M; Coker-Schwimmer, Emmanuel J L; Grodensky, Catherine A; Rosen, David L; Yuen, Andrea; Sista, Priyanka; Lohr, Kathleen N

2012-09-01

To assess the effectiveness of patient, provider, and systems interventions (Key Question [KQ] 1) or policy interventions (KQ 2) in improving medication adherence for an array of chronic health conditions. For interventions that are effective in improving adherence, we then assessed their effectiveness in improving health, health care utilization, and adverse events. MEDLINE®, the Cochrane Library. Additional studies were identified from reference lists and technical experts. Two people independently selected, extracted data from, and rated the risk of bias of relevant trials and systematic reviews. We synthesized the evidence for effectiveness separately for each clinical condition, and within each condition, by type of intervention. We also evaluated the prevalence of intervention components across clinical conditions and the effectiveness of interventions for a range of vulnerable populations. Two reviewers graded the strength of evidence using established criteria. We found a total of 62 eligible studies (58 trials and 4 observational studies) from our review of 3,979 abstracts. These studies included patients with diabetes, hyperlipidemia, hypertension, heart failure, myocardial infarction, asthma, depression, glaucoma, multiple sclerosis, musculoskeletal diseases, and multiple chronic conditions. Fifty-seven trials of patient, provider, or systems interventions (KQ 1) evaluated 20 different types of interventions; 4 observational studies and one trial of policy interventions (KQ 2) evaluated the effect of reduced out-of-pocket expenses or improved prescription drug coverage. We found the most consistent evidence of improvement in medication adherence for interventions to reduce out-of-pocket expenses or improve prescription drug coverage, case management, and educational interventions across clinical conditions. Within clinical conditions, we found the strongest support for self-management of medications for short-term improvement in adherence for asthma patients; collaborative care or case management programs for short-term improvement of adherence and to improve symptoms for patients taking depression medications; and pharmacist-led approaches for hypertensive patients to improve systolic blood pressure. Diverse interventions offer promising approaches to improving medication adherence for chronic conditions, particularly for the short term. Evidence on whether these approaches have broad applicability for clinical conditions and populations is limited, as is evidence regarding long-term medication adherence or health outcomes.

[Fusion of MRI, fMRI and intraoperative MRI data. Methods and clinical significance exemplified by neurosurgical interventions].

PubMed

Moche, M; Busse, H; Dannenberg, C; Schulz, T; Schmitgen, A; Trantakis, C; Winkler, D; Schmidt, F; Kahn, T

2001-11-01

The aim of this work was to realize and clinically evaluate an image fusion platform for the integration of preoperative MRI and fMRI data into the intraoperative images of an interventional MRI system with a focus on neurosurgical procedures. A vertically open 0.5 T MRI scanner was equipped with a dedicated navigation system enabling the registration of additional imaging modalities (MRI, fMRI, CT) with the intraoperatively acquired data sets. These merged image data served as the basis for interventional planning and multimodal navigation. So far, the system has been used in 70 neurosurgical interventions (13 of which involved image data fusion--requiring 15 minutes extra time). The augmented navigation system is characterized by a higher frame rate and a higher image quality as compared to the system-integrated navigation based on continuously acquired (near) real time images. Patient movement and tissue shifts can be immediately detected by monitoring the morphological differences between both navigation scenes. The multimodal image fusion allowed a refined navigation planning especially for the resection of deeply seated brain lesions or pathologies close to eloquent areas. Augmented intraoperative orientation and instrument guidance improve the safety and accuracy of neurosurgical interventions.

Multi-scale Modeling of the Cardiovascular System: Disease Development, Progression, and Clinical Intervention.

PubMed

Zhang, Yanhang; Barocas, Victor H; Berceli, Scott A; Clancy, Colleen E; Eckmann, David M; Garbey, Marc; Kassab, Ghassan S; Lochner, Donna R; McCulloch, Andrew D; Tran-Son-Tay, Roger; Trayanova, Natalia A

2016-09-01

Cardiovascular diseases (CVDs) are the leading cause of death in the western world. With the current development of clinical diagnostics to more accurately measure the extent and specifics of CVDs, a laudable goal is a better understanding of the structure-function relation in the cardiovascular system. Much of this fundamental understanding comes from the development and study of models that integrate biology, medicine, imaging, and biomechanics. Information from these models provides guidance for developing diagnostics, and implementation of these diagnostics to the clinical setting, in turn, provides data for refining the models. In this review, we introduce multi-scale and multi-physical models for understanding disease development, progression, and designing clinical interventions. We begin with multi-scale models of cardiac electrophysiology and mechanics for diagnosis, clinical decision support, personalized and precision medicine in cardiology with examples in arrhythmia and heart failure. We then introduce computational models of vasculature mechanics and associated mechanical forces for understanding vascular disease progression, designing clinical interventions, and elucidating mechanisms that underlie diverse vascular conditions. We conclude with a discussion of barriers that must be overcome to provide enhanced insights, predictions, and decisions in pre-clinical and clinical applications.

Multi-scale Modeling of the Cardiovascular System: Disease Development, Progression, and Clinical Intervention

PubMed Central

Zhang, Yanhang; Barocas, Victor H.; Berceli, Scott A.; Clancy, Colleen E.; Eckmann, David M.; Garbey, Marc; Kassab, Ghassan S.; Lochner, Donna R.; McCulloch, Andrew D.; Tran-Son-Tay, Roger; Trayanova, Natalia A.

2016-01-01

Cardiovascular diseases (CVDs) are the leading cause of death in the western world. With the current development of clinical diagnostics to more accurately measure the extent and specifics of CVDs, a laudable goal is a better understanding of the structure-function relation in the cardiovascular system. Much of this fundamental understanding comes from the development and study of models that integrate biology, medicine, imaging, and biomechanics. Information from these models provides guidance for developing diagnostics, and implementation of these diagnostics to the clinical setting, in turn, provides data for refining the models. In this review, we introduce multi-scale and multi-physical models for understanding disease development, progression, and designing clinical interventions. We begin with multi-scale models of cardiac electrophysiology and mechanics for diagnosis, clinical decision support, personalized and precision medicine in cardiology with examples in arrhythmia and heart failure. We then introduce computational models of vasculature mechanics and associated mechanical forces for understanding vascular disease progression, designing clinical interventions, and elucidating mechanisms that underlie diverse vascular conditions. We conclude with a discussion of barriers that must be overcome to provide enhanced insights, predictions, and decisions in pre-clinical and clinical applications. PMID:27138523

Effectiveness of an Adaptation of the Project Connect Health Systems Intervention: Youth and Clinic-Level Findings.

PubMed

Loosier, Penny S; Doll, Shelli; Lepar, Danielle; Ward, Kristin; Gamble, Ginger; Dittus, Patricia J

2016-08-01

The Project Connect Health Systems Intervention (Project Connect) uses a systematic process of collecting community and healthcare infrastructure information to craft a referral guide highlighting local healthcare providers who provide high quality sexual and reproductive healthcare. Previous self-report data on healthcare usage indicated Project Connect was successful with sexually experienced female youth, where it increased rates of human immunodeficiency virus (HIV) and sexually transmitted disease (STD) testing and receipt of contraception. This adaption of Project Connect examined its effectiveness in a new context and via collection of clinic encounter-level data. Project Connect was implemented in 3 high schools. (only 2 schools remained open throughout the entire project period). Participant recruitment and data collection occurred in 5 of 8 participating health clinics. Students completed Youth Surveys (N = 608) and a Clinic Survey (paired with medical data abstraction in 2 clinics [N = 305]). Students were more likely than nonstudents to report having reached a clinic via Project Connect. Nearly 40% of students attended a Project Connect school, with 32.7% using Project Connect to reach the clinic. Students were most likely to have been referred by a school nurse or coach. Project Connect is a low-cost, sustainable structural intervention with multiple applications within schools, either as a standalone intervention or in combination with ongoing efforts. © 2016, American School Health Association.

Current Status and Future Prospects of Clinical Psycholog

PubMed Central

Baker, Timothy B.; McFall, Richard M.; Shoham, Varda

2010-01-01

SUMMARY The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective–disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional–economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions. Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so. Clinical psychologists’ failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today’s clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student–faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge. A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands highquality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer highquality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health. PMID:20865146

Peer assisted learning in the clinical setting: an activity systems analysis.

PubMed

Bennett, Deirdre; O'Flynn, Siun; Kelly, Martina

2015-08-01

Peer assisted learning (PAL) is a common feature of medical education. Understanding of PAL has been based on processes and outcomes in controlled settings, such as clinical skills labs. PAL in the clinical setting, a complex learning environment, requires fresh evaluation. Socio-cultural theory is proposed as a means to understand educational interventions in ways that are practical and meaningful. We describe the evaluation of a PAL intervention, introduced to support students' transition into full time clinical attachments, using activity theory and activity systems analysis (ASA). Our research question was How does PAL transfer to the clinical environment? Junior students on their first clinical attachments undertook a weekly same-level, reciprocal PAL activity. Qualitative data was collected after each session, and focus groups (n = 3) were held on completion. Data was analysed using ASA. ASA revealed two competing activity systems on clinical attachment; Learning from Experts, which students saw as the primary function of the attachment and Learning with Peers, the PAL intervention. The latter took time from the first and was in tension with it. Tensions arose from student beliefs about how learning takes place in clinical settings, and the importance of social relationships, leading to variable engagement with PAL. Differing perspectives within the group were opportunities for expansive learning. PAL in the clinical environment presents challenges specific to that context. Using ASA helped to describe student activity on clinical attachment and to highlight tensions and contradictions relating PAL in that setting. Planning learning opportunities on clinical placements, must take account of how students learn in workplaces, and the complexity of the multiple competing activity systems related to learning and social activities.

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals

PubMed Central

Wu, Robert C; Lo, Vivian; Morra, Dante; Wong, Brian M; Sargeant, Robert; Locke, Ken; Cavalcanti, Rodrigo; Quan, Sherman D; Rossos, Peter; Tran, Kim; Cheung, Mark

2013-01-01

Background Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness. Objectives To describe the effects of different communication interventions and their problems. Design Prospective observational case study using a mixed methods approach of quantitative and qualitative methods. Setting General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals. Participants Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards. Methods Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010. Results We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories. Conclusions Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems. PMID:23355461

A clinical decision support system prototype for cardiovascular intensive care.

PubMed

Lau, F

1994-08-01

This paper describes the development and validation of a decision-support system prototype that can help manage hypovolemic hypotension in the Cardiovascular Intensive Care Unit (CVICU). The prototype uses physiologic pattern-matching, therapeutic protocols, computational drug-dosage response modeling and expert reasoning heuristics in its selection of intervention strategies and choices. As part of model testing, the prototype simulated real-time operation by processing historical physiologic and intervention data on a patient sequentially, generating alerts on questionable data, critiques of interventions instituted and recommendations on preferred interventions. Bench-testing with 399 interventions from 13 historical cases showed therapies for bleeding and fluid replacement proposed by the prototype were significantly more consistent (p < 0.0001) than those instituted by the staff when compared against expert critiques (80% versus 44%). This study has demonstrated the feasibility of formalizing hemodynamic management of CVICU patients in a manner that may be implemented and evaluated in a clinical setting.

Acceptance of clinical decision support surveillance technology in the clinical pharmacy.

PubMed

English, Dan; Ankem, Kalyani; English, Kathleen

2017-03-01

There are clinical and economic benefits to incorporating clinical decision support systems (CDSSs) in patient care interventions in the clinical pharmacy setting. However, user dissatisfaction and resistance to HIT can prevent optimal use of such systems, particularly when users employ system workarounds and overrides. The present study applied a modified version of the unified theory of acceptance and use of technology (UTAUT) to evaluate the disposition and satisfaction with CDSS among clinical pharmacists who perform surveillance to identify potential medication therapy interventions on patients in the hospital setting. A survey of clinical pharmacists (N = 48) was conducted. Partial least squares (PLS) regression was used to analyze the influence of the UTAUT-related variables on behavioral intention and satisfaction with CDSS among clinical pharmacists. While behavioral intention did not predict actual use of HIT, facilitating conditions had a direct effect on pharmacists' use of CDSS. Likewise, satisfaction with CDSS was found to have a direct effect on use, with more satisfied users being less inclined to employ workarounds or overrides of the system. Based on the findings, organizational structures that facilitate CDSS use and user satisfaction affect the extent to which pharmacy and health care management maximize use in the clinical pharmacy setting.

Clinical effort against secondhand smoke exposure: development of framework and intervention.

PubMed

Winickoff, Jonathan P; Park, Elyse R; Hipple, Bethany J; Berkowitz, Anna; Vieira, Cecilia; Friebely, Joan; Healey, Erica A; Rigotti, Nancy A

2008-08-01

The purpose of this work was to describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking. The scientific development of the intervention occurred in 3 stages. In stage 1, we designed an office system for parental tobacco control in the pediatric outpatient setting on the basis of complementary conceptual frameworks of preventive services delivery, conceptualized for the child health care setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidence-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage 2, we performed focus-group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype on the basis of this feedback to include 5 key implementation steps for the child health care setting. In stage 3, we presented the intervention to breakout groups at 2 national meetings of pediatric practitioners for additional refinements. The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The Clinical Effort Against Secondhand Smoke Exposure intervention was designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practice staff can choose materials relevant to their own particular systems of care (www.ceasetobacco.org). Conceptually grounded and focus-group-tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco-control intervention-development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.

Documenting clinical pharmacist intervention before and after the introduction of a web-based tool.

PubMed

Nurgat, Zubeir A; Al-Jazairi, Abdulrazaq S; Abu-Shraie, Nada; Al-Jedai, Ahmed

2011-04-01

To develop a database for documenting pharmacist intervention through a web-based application. The secondary endpoint was to determine if the new, web-based application provides any benefits with regards to documentation compliance by clinical pharmacists and ease of calculating cost savings compared with our previous method of documenting pharmacist interventions. A tertiary care hospital in Saudi Arabia. The documentation of interventions using a web-based documentation application was retrospectively compared with previous methods of documentation of clinical pharmacists' interventions (multi-user PC software). The number and types of interventions recorded by pharmacists, data mining of archived data, efficiency, cost savings, and the accuracy of the data generated. The number of documented clinical interventions increased from 4,926, using the multi-user PC software, to 6,840 for the web-based application. On average, we observed 653 interventions per clinical pharmacist using the web-based application, which showed an increase compared to an average of 493 interventions using the old multi-user PC software. However, using a paired Student's t-test there was no statistical significance difference between the two means (P = 0.201). Using a χ² test, which captured management level and the type of system used, we found a strong effect of management level (P < 2.2 × 10⁻¹⁶) on the number of documented interventions. We also found a moderately significant relationship between educational level and the number of interventions documented (P = 0.045). The mean ± SD time required to document an intervention using the web-based application was 66.55 ± 8.98 s. Using the web-based application, 29.06% of documented interventions resulted in cost-savings, while using the multi-user PC software only 4.75% of interventions did so. The majority of cost savings across both platforms resulted from the discontinuation of unnecessary drugs and a change in dosage regimen. Data collection using the web-based application was consistently more complete when compared to the multi-user PC software. The web-based application is an efficient system for documenting pharmacist interventions. Its flexibility and accessibility, as well as its detailed report functionality is a useful tool that will hopefully encourage other primary and secondary care facilities to adopt similar applications.

Application of system thinking concepts in health system strengthening in low-income settings: a proposed conceptual framework for the evaluation of a complex health system intervention: the case of the BHOMA intervention in Zambia.

PubMed

Mutale, Wilbroad; Balabanova, Dina; Chintu, Namwinga; Mwanamwenge, Margaret Tembo; Ayles, Helen

2016-02-01

The current drive to strengthen health systems provides an opportunity to develop new strategies that will enable countries to achieve targets for millennium development goals. In this paper, we present a proposed framework for evaluating a new health system strengthening intervention in Zambia known as Better Health Outcomes through Mentoring and Assessment. We briefly describe the intervention design and focus on the proposed evaluation approach through the lens of systems thinking. In this paper, we present a proposed framework to evaluate a complex health system intervention applying systems thinking concepts. We hope that lessons learnt from this process will help to adapt the intervention and limit unintended negative consequences while promoting positive effects. Emphasis will be paid to interaction and interdependence between health system building blocks, context and the community. © 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records.

PubMed

Müller-Staub, Maria; de Graaf-Waar, Helen; Paans, Wolter

2016-11-01

Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.

Effectiveness, usability, and cost-benefit of a virtual reality-based telerehabilitation program for balance recovery after stroke: a randomized controlled trial.

PubMed

Lloréns, Roberto; Noé, Enrique; Colomer, Carolina; Alcañiz, Mariano

2015-03-01

First, to evaluate the clinical effectiveness of a virtual reality (VR)-based telerehabilitation program in the balance recovery of individuals with hemiparesis after stroke in comparison with an in-clinic program; second, to compare the subjective experiences; and third, to contrast the costs of both programs. Single-blind, randomized, controlled trial. Neurorehabilitation unit. Chronic outpatients with stroke (N=30) with residual hemiparesis. Twenty 45-minute training sessions with the telerehabilitation system, conducted 3 times a week, in the clinic or in the home. First, Berg Balance Scale for balance assessment. The Performance-Oriented Mobility Assessment balance and gait subscales, and the Brunel Balance Assessment were secondary outcome measures. Clinical assessments were conducted at baseline, 8 weeks (posttreatment), and 12 weeks (follow-up). Second, the System Usability Scale and the Intrinsic Motivation Inventory for subjective experiences. Third, cost (in dollars). Significant improvement in both groups (in-clinic group [control] and a home-based telerehabilitation group) from the initial to the final assessment in the Berg Balance Scale (ηp(2)=.68; P=.001), in the balance (ηp(2)=.24; P=.006) and gait (ηp(2)=.57, P=.001) subscales of the Tinetti Performance-Oriented Mobility Assessment, and in the Brunel Balance Assessment (control: χ(2)=15.0; P=.002; experimental: χ(2)=21.9; P=.001). No significant differences were found between the groups in any balance scale or in the feedback questionnaires. With regard to subjective experiences, both groups considered the VR system similarly usable and motivating. The in-clinic intervention resulted in more expenses than did the telerehabilitation intervention ($654.72 per person). First, VR-based telerehabilitation interventions can promote the reacquisition of locomotor skills associated with balance in the same way as do in-clinic interventions, both complemented with a conventional therapy program; second, the usability of and motivation to use the 2 interventions can be similar; and third, telerehabilitation interventions can involve savings that vary depending on each scenario. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Cardiac output and systemic vascular resistance: Clinical assessment compared with a noninvasive objective measurement in children with shock.

PubMed

Razavi, Asma; Newth, Christopher J L; Khemani, Robinder G; Beltramo, Fernando; Ross, Patrick A

2017-06-01

To evaluate physician assessment of cardiac output and systemic vascular resistance in patients with shock compared with an ultrasonic cardiac output monitor (USCOM). To explore potential changes in therapy decisions if USCOM data were available using physician intervention answers. Double-blinded, prospective, observational study in a tertiary hospital pediatric intensive care unit. Forty children (<18years) admitted with shock, requiring ongoing volume resuscitation or inotropic support. Two to 3 physicians clinically assessed cardiac output and systemic vascular resistance, categorizing them as high, normal, or low. An investigator simultaneously measured cardiac index (CI) and systemic vascular resistance index (SVRI) with USCOM categorized as high, normal, or low. Overall agreement between physician and USCOM for CI (48.5% [κ = 0.18]) and SVRI (45.9% [κ = 0.16]) was poor. Interobserver agreement was also poor for CI (58.7% [κ = 0.33]) and SVRI (52.3% [κ = 0.28]). Comparing theoretical physician interventions to "acceptable" or "unacceptable" clinical interventions, based on USCOM measurement, 56 (21%) physician interventions were found to be "unacceptable." There is poor agreement between physician-assessed CI and SVRI and USCOM, with significant interobserver variability among physicians. Objective measurement of CI and SVRI may reduce variability and improve diagnostic accuracy. Copyright © 2016 Elsevier Inc. All rights reserved.

A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol

PubMed Central

2013-01-01

Background Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care. Methods Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions. Discussion As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities. Trial Registration ClinicalTrials.gov NCT01566864 PMID:23734703

CT-Guided Interventions Using a Free-Hand, Optical Tracking System: Initial Clinical Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Schubert, Tilman, E-mail: TSchubert@uhbs.ch; Jacob, Augustinus L.; Pansini, Michele

2013-08-01

PurposeThe present study was designed to evaluate the geometrical accuracy and clinical applicability of a new, free-hand, CT-guided, optical navigation system.MethodsFifteen procedures in 14 consecutive patients were retrospectively analyzed. The navigation system was applied for interventional procedures on small target lesions, in cases with long needle paths, narrow access windows, or when an out-of-plane access was expected. Mean lesion volume was 27.9 ml, and mean distance to target measured was 107.5 mm. Eleven of 15 needle trajectories were planned as out-of-plane approaches regarding the axial CT plane.ResultsNinety-one percent of the biopsies were diagnostic. All therapeutic interventions were technically successful. Targetingmore » precision was high with a mean distance of the needle tip from planned target of 1.98 mm. Mean intervention time was 1:12 h. A statistically significant correlation between angular needle deviation and intervention time (p = 0.007), respiratory movement of the target (p = 0.008), and body mass index (p = 0.02) was detected. None of the evaluated parameters correlated significantly with the distance from the needle tip to the planned target.ConclusionsThe application of a navigation system for complex CT-guided procedures provided safe and effective targeting within a reasonable intervention time in our series.« less

Supportive intervention using a mobile phone in behavior modification.

PubMed

Hareva, David H; Okada, Hiroki; Kitawaki, Tomoki; Oka, Hisao

2009-04-01

The authors previously developed a mobile ecological momentary assessment (EMA) system as a real-time data collection device using a mobile phone. In this study, a real-time advice function and real-time reporting function were added to the previous system as a supportive intervention. The improved system was found to work effectively and was applied to several clinical cases, including patients with depressive disorder, dizziness, smoking habit, and bronchial asthma. The average patient compliance rate was high (89%) without the real-time advice and higher (93%) with the advice. The trends in clinical data for patients using a mobile EMA with/without the new function were analyzed for up to several months. In the case of dizziness, an improving trend in its clinical data was observed after applying the real-time advice, and in the case of depressive disorder, a stabilizing trend was observed. The mobile EMA system with the real-time advice function could be useful as a supportive intervention in behavior modification and for motivating patients in self-management of their disease.

Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer

PubMed Central

Hamel, Lauren M.; Penner, Louis A.; Albrecht, Terrance L.; Heath, Elisabeth; Gwede, Clement K.; Eggly, Susan

2016-01-01

Background Clinical trials that study cancer are essential for testing the safety and effectiveness of promising treatments, but most people with cancer never enroll in a clinical trial — a challenge exemplified in racial and ethnic minorities. Underenrollment of racial and ethnic minorities reduces the generalizability of research findings and represents a disparity in access to high-quality health care. Methods Using a multilevel model as a framework, potential barriers to trial enrollment of racial and ethnic minorities were identified at system, individual, and interpersonal levels. Exactly how each level directly or indirectly contributes to doctor–patient communication was also reviewed. Selected examples of implemented interventions are included to help address these barriers. We then propose our own evidence-based intervention addressing barriers at the individual and interpersonal levels. Results Barriers to enrolling a diverse population of patients in clinical trials are complex and multilevel. Interventions focused at each level have been relatively successful, but multilevel interventions have the greatest potential for success. Conclusion To increase the enrollment of racial and ethnic minorities in clinical trials, future interventions should address barriers at multiple levels. PMID:27842322

Visual tracking for multi-modality computer-assisted image guidance

NASA Astrophysics Data System (ADS)

Basafa, Ehsan; Foroughi, Pezhman; Hossbach, Martin; Bhanushali, Jasmine; Stolka, Philipp

2017-03-01

With optical cameras, many interventional navigation tasks previously relying on EM, optical, or mechanical guidance can be performed robustly, quickly, and conveniently. We developed a family of novel guidance systems based on wide-spectrum cameras and vision algorithms for real-time tracking of interventional instruments and multi-modality markers. These navigation systems support the localization of anatomical targets, support placement of imaging probe and instruments, and provide fusion imaging. The unique architecture - low-cost, miniature, in-hand stereo vision cameras fitted directly to imaging probes - allows for an intuitive workflow that fits a wide variety of specialties such as anesthesiology, interventional radiology, interventional oncology, emergency medicine, urology, and others, many of which see increasing pressure to utilize medical imaging and especially ultrasound, but have yet to develop the requisite skills for reliable success. We developed a modular system, consisting of hardware (the Optical Head containing the mini cameras) and software (components for visual instrument tracking with or without specialized visual features, fully automated marker segmentation from a variety of 3D imaging modalities, visual observation of meshes of widely separated markers, instant automatic registration, and target tracking and guidance on real-time multi-modality fusion views). From these components, we implemented a family of distinct clinical and pre-clinical systems (for combinations of ultrasound, CT, CBCT, and MRI), most of which have international regulatory clearance for clinical use. We present technical and clinical results on phantoms, ex- and in-vivo animals, and patients.

Accuracy Considerations in Image-guided Cardiac Interventions: Experience and Lessons Learned

PubMed Central

Linte, Cristian A.; Lang, Pencilla; Rettmann, Maryam E.; Cho, Daniel S.; Holmes, David R.; Robb, Richard A.; Peters, Terry M.

2014-01-01

Motivation Medical imaging and its application in interventional guidance has revolutionized the development of minimally invasive surgical procedures leading to reduced patient trauma, fewer risks, and shorter recovery times. However, a frequently posed question with regards to an image guidance system is “how accurate is it?” On one hand, the accuracy challenge can be posed in terms of the tolerable clinical error associated with the procedure; on the other hand, accuracy is bound by the limitations of the system’s components, including modeling, patient registration, and surgical instrument tracking, all of which ultimately impact the overall targeting capabilities of the system. Methods While these processes are not unique to any interventional specialty, this paper discusses them in the context of two different cardiac image-guidance platforms: a model-enhanced ultrasound platform for intracardiac interventions and a prototype system for advanced visualization in image-guided cardiac ablation therapy. Results Pre-operative modeling techniques involving manual, semi-automatic and registration-based segmentation are discussed. The performance and limitations of clinically feasible approaches for patient registration evaluated both in the laboratory and operating room are presented. Our experience with two different magnetic tracking systems for instrument and ultrasound transducer localization is reported. Ultimately, the overall accuracy of the systems is discussed based on both in vitro and preliminary in vivo experience. Conclusion While clinical accuracy is specific to a particular patient and procedure and vastly dependent on the surgeon’s experience, the system’s engineering limitations are critical to determine whether the clinical requirements can be met. PMID:21671097

Evaluation of the clinical benefit of an electromagnetic navigation system for CT-guided interventional radiology procedures in the thoraco-abdominal region compared with conventional CT guidance (CTNAV II): study protocol for a randomised controlled trial.

PubMed

Rouchy, R C; Moreau-Gaudry, A; Chipon, E; Aubry, S; Pazart, L; Lapuyade, B; Durand, M; Hajjam, M; Pottier, S; Renard, B; Logier, R; Orry, X; Cherifi, A; Quehen, E; Kervio, G; Favelle, O; Patat, F; De Kerviler, E; Hughes, C; Medici, M; Ghelfi, J; Mounier, A; Bricault, I

2017-07-06

Interventional radiology includes a range of minimally invasive image-guided diagnostic and therapeutic procedures that have become routine clinical practice. Each procedure involves a percutaneous needle insertion, often guided using computed tomography (CT) because of its availability and usability. However, procedures remain complicated, in particular when an obstacle must be avoided, meaning that an oblique trajectory is required. Navigation systems track the operator's instruments, meaning the position and progression of the instruments are visualised in real time on the patient's images. A novel electromagnetic navigation system for CT-guided interventional procedures (IMACTIS-CT®) has been developed, and a previous clinical trial demonstrated improved needle placement accuracy in navigation-assisted procedures. In the present trial, we are evaluating the clinical benefit of the navigation system during the needle insertion step of CT-guided procedures in the thoraco-abdominal region. This study is designed as an open, multicentre, prospective, randomised, controlled interventional clinical trial and is structured as a standard two-arm, parallel-design, individually randomised trial. A maximum of 500 patients will be enrolled. In the experimental arm (navigation system), the procedures are carried out using navigation assistance, and in the active comparator arm (CT), the procedures are carried out with conventional CT guidance. The randomisation is stratified by centre and by the expected difficulty of the procedure. The primary outcome of the trial is a combined criterion to assess the safety (number of serious adverse events), efficacy (number of targets reached) and performance (number of control scans acquired) of navigation-assisted, CT-guided procedures as evaluated by a blinded radiologist and confirmed by an expert committee in case of discordance. The secondary outcomes are (1) the duration of the procedure, (2) the satisfaction of the operator and (3) the irradiation dose delivered, with (4) subgroup analysis according to the expected difficulty of the procedure, as well as an evaluation of (5) the usability of the device. This trial addresses the lack of published high-level evidence studies in which navigation-assisted CT-guided interventional procedures are evaluated. This trial is important because it addresses the problems associated with conventional CT guidance and is particularly relevant because the number of interventional radiology procedures carried out in routine clinical practice is increasing. ClinicalTrials.gov identifier: NCT01896219 . Registered on 5 July 2013.

Performance characteristics of an interventional multispectral photoacoustic imaging system for guiding minimally invasive procedures

PubMed Central

Mari, Jean Martial; West, Simeon J.; Pratt, Rosalind; David, Anna L.; Ourselin, Sebastien; Beard, Paul C.; Desjardins, Adrien E.

2016-01-01

Precise device guidance is important for interventional procedures in many different clinical fields including fetal medicine, regional anesthesia, interventional pain management, and interventional oncology. While ultrasound is widely used in clinical practice for real-time guidance, the image contrast that it provides can be insufficient for visualizing tissue structures such as blood vessels, nerves, and tumors. This study was centered on the development of a photoacoustic imaging system for interventional procedures that delivered excitation light in the ranges of 750 to 900 nm and 1150 to 1300 nm, with an optical fiber positioned in a needle cannula. Coregistered B-mode ultrasound images were obtained. The system, which was based on a commercial ultrasound imaging scanner, has an axial resolution in the vicinity of 100 μm and a submillimeter, depth-dependent lateral resolution. Using a tissue phantom and 800 nm excitation light, a simulated blood vessel could be visualized at a maximum distance of 15 mm from the needle tip. Spectroscopic contrast for hemoglobin and lipids was observed with ex vivo tissue samples, with photoacoustic signal maxima consistent with the respective optical absorption spectra. The potential for further optimization of the system is discussed. PMID:26263417

The feasibility, time savings and economic impact of a designated time appointment system at a busy HIV care clinic in Kenya: a randomized controlled trial.

PubMed

Kwena, Zachary A; Njoroge, Betty W; Cohen, Craig R; Oyaro, Patrick; Shikari, Rosemary; Kibaara, Charles K; Bukusi, Elizabeth A

2015-01-01

As efforts are made to reach universal access to ART in Kenya, the problem of congestion at HIV care clinics is likely to worsen. We evaluated the feasibility and the economic benefits of a designated time appointment system as a solution to decongest HIV care clinics. This was an explanatory two-arm open-label randomized controlled trial that enrolled 354 consenting participants during their normal clinic days and followed-up at subsequent clinic appointments for up to nine months. Intervention arm participants were given specific dates and times to arrive at the clinic for their next appointment while those in the control arm were only given the date and had the discretion to decide on the time to arrive as is the standard practice. At follow-up visits, we recorded arrival and departure times and asked the monetary value of work participants engaged in before and after clinic. We conducted multiple imputation to replace missing data in our primary outcome variables to allow for intention-to-treat analysis; and analyzed the data using Mann-Whitney U test. Overall, 72.1% of the intervention participants arrived on time, 13.3% arrived ahead of time and 14.6% arrived past scheduled time. Intervention arm participants spent a median of 65 [interquartile range (IQR), 52-87] minutes at the clinic compared to 197 (IQR, 173-225) minutes for control participants (p<0.01). Furthermore, intervention arm participants were more productively engaged on their clinic days valuing their cumulative work at a median of USD 10.5 (IQR, 60.0-16.8) compared to participants enrolled in the control arm who valued their work at USD 8.3 (IQR, 5.5-12.9; p=0.02). A designated time appointment system is feasible and provides substantial time savings associated with greater economic productivity for HIV patients attending a busy HIV care clinic.

[First clinical experience with extended planning and navigation in an interventional MRI unit].

PubMed

Moche, M; Schmitgen, A; Schneider, J P; Bublat, M; Schulz, T; Voerkel, C; Trantakis, C; Bennek, J; Kahn, T; Busse, H

2004-07-01

To present an advanced concept for patient-based navigation and to report on our first clinical experience with interventions in the cranium, of soft-tissue structures (breast, liver) and in the musculoskeletal system. A PC-based navigation system was integrated into an existing interventional MRI environment. Intraoperatively acquired 3D data were used for interventional planning. The information content of these reference data was increased by integration of additional image modalities (e. g., fMRI, CT) and by color display of areas with early contrast media enhancement. Within 18 months, the system was used in 123 patients undergoing interventions in different anatomic regions (brain: 64, paranasal sinus: 9, breast: 20, liver: 17, bone: 9, muscle: 4). The mean duration of 64 brain interventions was compared with that of 36 procedures using the scanner's standard navigation. In contrast with the continuous scanning mode of the MR system (0.25 fps), the higher quality as well as the real time display (4 fps) of the MR images reconstructed from the 3D reference data allowed adequate hand-eye coordination. With our system, patient movement and tissue shifts could be immediately detected intraoperatively, and, in contrast to the standard procedure, navigation safely resumed after updating the reference data. The navigation system was characterized by good stability, efficient system integration and easy usability. Despite additional working steps still to be optimized, the duration of the image-guided brain tumor resections was not significantly longer. The presented system combines the advantage of intraoperative MRI with established visualization, planning, and real time capabilities of neuronavigation and can be efficiently applied in a broad range of non-neurosurgical interventions.

A qualitative investigation into the usefulness and impact of the performance intervention zone system used in the diagnostic assessment of internationally educated massage therapists.

PubMed

Finch, Paul; Baskwill, Amanda

2011-04-01

Previous work (Finch, 2008) reported on the development and implementation of a safety oriented system of performance intervention zones (PIZ), which was used in the assessment of internationally educated massage therapists. The study reported in this paper explores the usefulness and impact of the system as experienced by the evaluators involved in the diagnostic assessment. This exploratory research was of a qualitative design in which data were collected during a series of individual semi-structured interviews with evaluators who used the performance intervention zone system during the diagnostic assessment of internationally educated massage therapists in Ontario. After obtaining informed consent, interviews were taped, transcribed and analyzed, resulting in identification of a number of themes and recommendations regarding future use and development of the system. Analysis revealed four themes within the data. These were that the performance intervention zone system 1) enhanced the confidence of examiners in their ability to conduct the comprehensive clinical examination effectively, 2) assisted and improved examiner decision making during the examination, 3) was a useful aid to communication regarding candidate performance, and 4) could be improved by clarifying the nature of intervention and implementing more extensive examiner training prior to the examination. The performance intervention zone system was found to be useful in orienting examiners to the evaluation process, in supporting decision making during the comprehensive clinical evaluation and as an aid to communication in the post-examination review of candidate performance. The system could be improved through implementation of a pre-examination workshop focused on use of the PIZ and by delineation of levels of examiner intervention during the examination. Copyright © 2010 Elsevier Ltd. All rights reserved.

Interventions to Improve the Response of Professionals to Children Exposed to Domestic Violence and Abuse: A Systematic Review.

PubMed

Turner, William; Hester, Marianne; Broad, Jonathan; Szilassy, Eszter; Feder, Gene; Drinkwater, Jessica; Firth, Adam; Stanley, Nicky

2017-01-01

Exposure of children to domestic violence and abuse (DVA) is a form of child maltreatment with short- and long-term behavioural and mental health impact. Health care professionals are generally uncertain about how to respond to domestic violence and are particularly unclear about best practice with regards to children's exposure and their role in a multiagency response. In this systematic review, we report educational and structural or whole-system interventions that aim to improve professionals' understanding of, and response to, DVA survivors and their children. We searched 22 bibliographic databases and contacted topic experts for studies reporting quantitative outcomes for any type of intervention aiming to improve professional responses to disclosure of DVA with child involvement. We included interventions for physicians, nurses, social workers and teachers. Twenty-one studies met the inclusion criteria: three randomised controlled trials (RCTs), 18 pre-post intervention surveys. There were 18 training and three system-level interventions. Training interventions generally had positive effects on participants' knowledge, attitudes towards DVA and clinical competence. The results from the RCTs were consistent with the before-after surveys. Results from system-level interventions aimed to change organisational practice and inter-organisational collaboration demonstrates the benefit of coordinating system change in child welfare agencies with primary health care and other organisations. Implications for policy and research are discussed. © 2015 The Authors. Child Abuse Review published by John Wiley & Sons Ltd. 'We searched 22 bibliographic databases and contacted topic experts'. We reviewed published evidence on interventions aimed at improving professionals' practice with domestic violence survivors and their children.Training programmes were found to improve participants' knowledge, attitudes and clinical competence up to a year after delivery.Key elements of successful training include interactive discussion, booster sessions and involving specialist domestic violence practitioners.Whole-system approaches aiming to promote coordination and collaboration across agencies appear promising but require funding and high levels of commitment from partners. 'Training programmes were found to improve participants' knowledge, attitudes and clinical competence up to a year after delivery'.

Mapping the Early Intervention System in Ontario, Canada

ERIC Educational Resources Information Center

Underwood, Kathryn

2012-01-01

This study documents the wide range of early intervention services across the province of Ontario. The services are mapped across the province showing geographic information as well as the scope of services (clinical, family-based, resource support, etc.), the range of early intervention professionals, sources of funding and the populations served…

A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study.

PubMed

Siedner, Mark J; Santorino, Data; Lankowski, Alexander J; Kanyesigye, Michael; Bwana, Mwebesa B; Haberer, Jessica E; Bangsberg, David R

2015-07-06

Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors. We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January - August 2012) served as a control group. Participants in the intervention period (September 2012 - November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading "ABCDEFG" to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation. There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11-49) in the pre-intervention period and 6 days (IQR 3-16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11-75) versus 12 days (IQR 5-19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period). A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results. Clinicaltrials.gov NCT01579214 , approved 13 April 2012.

The Dutch Hospital Standardised Mortality Ratio (HSMR) method and cardiac surgery: benchmarking in a national cohort using hospital administration data versus a clinical database

PubMed Central

Siregar, S; Pouw, M E; Moons, K G M; Versteegh, M I M; Bots, M L; van der Graaf, Y; Kalkman, C J; van Herwerden, L A; Groenwold, R H H

2014-01-01

Objective To compare the accuracy of data from hospital administration databases and a national clinical cardiac surgery database and to compare the performance of the Dutch hospital standardised mortality ratio (HSMR) method and the logistic European System for Cardiac Operative Risk Evaluation, for the purpose of benchmarking of mortality across hospitals. Methods Information on all patients undergoing cardiac surgery between 1 January 2007 and 31 December 2010 in 10 centres was extracted from The Netherlands Association for Cardio-Thoracic Surgery database and the Hospital Discharge Registry. The number of cardiac surgery interventions was compared between both databases. The European System for Cardiac Operative Risk Evaluation and hospital standardised mortality ratio models were updated in the study population and compared using the C-statistic, calibration plots and the Brier-score. Results The number of cardiac surgery interventions performed could not be assessed using the administrative database as the intervention code was incorrect in 1.4–26.3%, depending on the type of intervention. In 7.3% no intervention code was registered. The updated administrative model was inferior to the updated clinical model with respect to discrimination (c-statistic of 0.77 vs 0.85, p<0.001) and calibration (Brier Score of 2.8% vs 2.6%, p<0.001, maximum score 3.0%). Two average performing hospitals according to the clinical model became outliers when benchmarking was performed using the administrative model. Conclusions In cardiac surgery, administrative data are less suitable than clinical data for the purpose of benchmarking. The use of either administrative or clinical risk-adjustment models can affect the outlier status of hospitals. Risk-adjustment models including procedure-specific clinical risk factors are recommended. PMID:24334377

Open-source platforms for navigated image-guided interventions.

PubMed

Ungi, Tamas; Lasso, Andras; Fichtinger, Gabor

2016-10-01

Navigation technology is changing the clinical standards in medical interventions by making existing procedures more accurate, and new procedures possible. Navigation is based on preoperative or intraoperative imaging combined with 3-dimensional position tracking of interventional tools registered to the images. Research of navigation technology in medical interventions requires significant engineering efforts. The difficulty of developing such complex systems has been limiting the clinical translation of new methods and ideas. A key to the future success of this field is to provide researchers with platforms that allow rapid implementation of applications with minimal resources spent on reimplementing existing system features. A number of platforms have been already developed that can share data in real time through standard interfaces. Complete navigation systems can be built using these platforms using a layered software architecture. In this paper, we review the most popular platforms, and show an effective way to take advantage of them through an example surgical navigation application. Copyright © 2016 Elsevier B.V. All rights reserved.

Recruitment experience for a pragmatic randomized controlled trial: Using EMR initiatives and minimizing research infrastructure.

PubMed

Joseph, Christine Lm; Ownby, Dennis R; Zoratti, Edward; Johnson, Dayna; Considine, Shannon; Bourgeois, Renee; Melkonian, Christina; Miree, Cheryl; Johnson, Christine Cole; Lu, Mei

2016-01-01

Modernized approaches to multisite randomized controlled trials (RCT) include the use of electronic medical records (EMR) for recruitment, remote data capture (RDC) for multisite data collection, and strategies to reduce the need for research infrastructure. These features facilitate the conduct of pragmatic trials, or trials conducted in "real life" settings. We describe the recruitment experience of an RCT to evaluate a clinic-based intervention targeting urban youth with asthma. Using encounter and prescription databases, a list of potentially-eligible patients was linked to the Epic appointment scheduling system. Patients were enrolled during a scheduled visit and then electronically randomized to a tailored versus generic online intervention. 1146 appointments for 580 eligible patients visiting 5 clinics were identified, of which 45.9% (266/580) were randomized to reach targeted enrollment (n=250). RDC facilitated multisite enrollment. Intervention content was further personalized through real- time entry of asthma medications prescribed at the clinic visit. EMR monitoring helped with recruitment trouble-shooting. Systemic challenges included a system-wide EMR transition and a system-wide reorganization of clinic staffing. Modernized RCTs can accelerate translation of research findings. Electronic initiatives facilitated implementation of this RCT; however, adaptations to recruitment strategies resulted in a more "explanatory" framework. .

Effectiveness of an Adaptation of the Project Connect Health Systems Intervention: Youth and Clinic-Level Findings

ERIC Educational Resources Information Center

Loosier, Penny S.; Doll, Shelli; Lepar, Danielle; Ward, Kristin; Gamble, Ginger; Dittus, Patricia J.

2016-01-01

Background: The Project Connect Health Systems Intervention (Project Connect) uses a systematic process of collecting community and healthcare infrastructure information to craft a referral guide highlighting local healthcare providers who provide high quality sexual and reproductive healthcare. Previous self-report data on healthcare usage…

[Robotics].

PubMed

Bier, J

2000-05-01

Content of this paper is the current state of the art of robots in surgery and the ongoing work on the field of surgical robotics at the Clinic for Maxillofacial Surgery at the Charité. Robots in surgery allows the surgeon to transform the accuracy of the imaging systems directly during the intervention and to plan an intervention beforehand. In this paper firstly the state of the art is described. Subsequently the scientific work at the clinic is described in detail. The paper closes with a outlook for future applications of robotics systems in maxillofacial surgery.

Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives.

PubMed

Von Korff, Michael; Walker, Rod L; Saunders, Kathleen; Shortreed, Susan M; Thakral, Manu; Parchman, Michael; Hansen, Ryan N; Ludman, Evette; Sherman, Karen J; Dublin, Sascha

2017-08-01

No studies have assessed the comparative effectiveness of guideline-recommended interventions to reduce risk of prescription opioid use disorder among chronic opioid therapy (COT) patients. We compared the prevalence of prescription opioid use disorder among COT patients from intervention clinics that had implemented opioid dose and risk reduction initiatives for more than 4 years relative to control clinics that had not. After a healthcare system in Washington State implemented interventions to reduce opioid dose and risks, we surveyed 1588 adult primary care COT patients to compare the prevalence of prescription opioid use disorder among COT patients from the intervention and control clinics. Intervention clinics managed COT patients at lower COT doses and with more consistent use of risk reduction practices. Control clinics cared for similar COT patients but prescribed higher opioid doses and used COT risk reduction practices inconsistently. Prescription opioid use disorder was assessed with the Psychiatric Research Interview for Substance and Mental Disorders. The prevalence of prescription opioid use disorder was 21.5% (95% CI=18.9% to 24.4%) among COT patients in the intervention clinics and 23.9% (95% CI=20.5% to 27.6%) among COT patients in the control clinics. The adjusted relative risk of prescription opioid use disorder was 1.08 (95% CI=0.89, 1.32) among the control clinic patients relative to the intervention clinic patients. Long-term implementation of opioid dose and risk reduction initiatives was not associated with lower rates of prescription opioid use disorder among prevalent COT patients. Extreme caution should be exercised by clinicians considering COT for patients with chronic non-cancer pain until benefits of this treatment and attendant risks are clarified. Copyright © 2017 Elsevier B.V. All rights reserved.

Knowledge translation of the American College of Emergency Physicians' clinical policy on syncope using computerized clinical decision support.

PubMed

Melnick, Edward R; Genes, Nicholas G; Chawla, Neal K; Akerman, Meredith; Baumlin, Kevin M; Jagoda, Andy

2010-06-01

To influence physician practice behavior after implementation of a computerized clinical decision support system (CDSS) based upon the recommendations from the 2007 ACEP Clinical Policy on Syncope. This was a pre-post intervention with a prospective cohort and retrospective controls. We conducted a medical chart review of consecutive adult patients with syncope. A computerized CDSS prompting physicians to explain their decision-making regarding imaging and admission in syncope patients based upon ACEP Clinical Policy recommendations was embedded into the emergency department information system (EDIS). The medical records of 410 consecutive adult patients presenting with syncope were reviewed prior to implementation, and 301 records were reviewed after implementation. Primary outcomes were physician practice behavior demonstrated by admission rate and rate of head computed tomography (CT) imaging before and after implementation. There was a significant difference in admission rate pre- and post-intervention (68.1% vs. 60.5% respectively, p = 0.036). There was no significant difference in the head CT imaging rate pre- and post-intervention (39.8% vs. 43.2%, p = 0.358). There were seven physicians who saw ten or more patients during the pre- and post-intervention. Subset analysis of these seven physicians' practice behavior revealed a slight significant difference in the admission rate pre- and post-intervention (74.3% vs. 63.9%, p = 0.0495) and no significant difference in the head CT scan rate pre- and post-intervention (42.9% vs. 45.4%, p = 0.660). The introduction of an evidence-based CDSS based upon ACEP Clinical Policy recommendations on syncope correlated with a change in physician practice behavior in an urban academic emergency department. This change suggests emergency medicine clinical practice guideline recommendations can be incorporated into the physician workflow of an EDIS to enhance the quality of practice.

A medical informatics perspective on clinical decision support systems. Findings from the yearbook 2013 section on decision support.

PubMed

Bouaud, J; Lamy, J-B

2013-01-01

To summarize excellent research and to select best papers published in 2012 in the field of computer-based decision support in healthcare. A bibliographic search focused on clinical decision support systems (CDSSs) and computer provider order entry was performed, followed by a double-blind literature review. The review process yielded six papers, illustrating various aspects of clinical decision support. The first paper is a systematic review of CDSS intervention trials in real settings, and considers different types of possible outcomes. It emphasizes the heterogeneity of studies and confirms that CDSSs can improve process measures but that evidence lacks for other types of outcomes, especially clinical or economic. Four other papers tackle the safety of drug prescribing and show that CDSSs can be efficient in reducing prescription errors. The sixth paper exemplifies the growing role of ontological resources which can be used for several applications including decision support. CDSS research has to be continuously developed and assessed. The wide variety of systems and of interventions limits the understanding of factors of success of CDSS implementations. A standardization in the characterization of CDSSs and of intervention trial reporting will help to overcome this obstacle.

An MRI-Compatible Robotic System With Hybrid Tracking for MRI-Guided Prostate Intervention

PubMed Central

Krieger, Axel; Iordachita, Iulian I.; Guion, Peter; Singh, Anurag K.; Kaushal, Aradhana; Ménard, Cynthia; Pinto, Peter A.; Camphausen, Kevin; Fichtinger, Gabor

2012-01-01

This paper reports the development, evaluation, and first clinical trials of the access to the prostate tissue (APT) II system—a scanner independent system for magnetic resonance imaging (MRI)-guided transrectal prostate interventions. The system utilizes novel manipulator mechanics employing a steerable needle channel and a novel six degree-of-freedom hybrid tracking method, comprising passive fiducial tracking for initial registration and subsequent incremental motion measurements. Targeting accuracy of the system in prostate phantom experiments and two clinical human-subject procedures is shown to compare favorably with existing systems using passive and active tracking methods. The portable design of the APT II system, using only standard MRI image sequences and minimal custom scanner interfacing, allows the system to be easily used on different MRI scanners. PMID:22009867

Development of a Smartphone-Enabled Hypertension and Diabetes Mellitus Management Package to Facilitate Evidence-Based Care Delivery in Primary Healthcare Facilities in India: The mPower Heart Project.

PubMed

Ajay, Vamadevan S; Jindal, Devraj; Roy, Ambuj; Venugopal, Vidya; Sharma, Rakshit; Pawar, Abha; Kinra, Sanjay; Tandon, Nikhil; Prabhakaran, Dorairaj

2016-12-21

The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide. The mPower Heart Project aimed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task-sharing with the use of a mobile phone-based clinical decision support system at Community Health Centers in Himachal Pradesh, India. The development of the intervention and mobile phone-based clinical decision support system was carried out using mixed methods in five Community Health Centers. The intervention was subsequently evaluated using pre-post evaluation design. During intervention, a nurse care coordinator screened, examined, and entered patient parameters into mobile phone-based clinical decision support system to generate a prescription, which was vetted by a physician. The change in systolic blood pressure, diastolic blood pressure, and fasting plasma glucose (FPG) over 18 months of intervention was quantified using generalized estimating equations models. During intervention, 6797 participants were enrolled. Six thousand sixteen participants had hypertension (mean systolic blood pressure: 146.1 mm Hg, 95% CI: 145.7, 146.5; diastolic blood pressure: 89.52 mm Hg, 95% CI: 89.33, 89.72), of which 3152 (52%) subjects were newly detected. Similarly, 1516 participants had diabetes mellitus (mean FPG: 177.9 mg/dL, 95% CI: 175.8, 180.0), of which 450 (30%) subjects were newly detected. The changes in systolic blood pressure, diastolic blood pressure, and FPG observed at 18 months of follow-up were -14.6 mm Hg (95% CI: -15.3, -13.8), -7.6 mm Hg (CI: -8.0, -7.2), and -50.0 mg/dL (95% CI: -54.6, -45.5), respectively, and were statistically significant even after adjusting for age, sex, and Community Health Center. A nurse-facilitated, mobile phone-based clinical decision support system-enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale-up in resource poor settings. URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01794052. Clinical Trial Registry-India: CTRI/2013/02/003412. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Design of a Competency Evaluation Model for Clinical Nursing Practicum, Based on Standardized Language Systems: Psychometric Validation Study.

PubMed

Iglesias-Parra, Maria Rosa; García-Guerrero, Alfonso; García-Mayor, Silvia; Kaknani-Uttumchandani, Shakira; León-Campos, Álvaro; Morales-Asencio, José Miguel

2015-07-01

To develop an evaluation system of clinical competencies for the practicum of nursing students based on the Nursing Interventions Classification (NIC). Psychometric validation study: the first two phases addressed definition and content validation, and the third phase consisted of a cross-sectional study for analyzing reliability. The study population was undergraduate nursing students and clinical tutors. Through the Delphi technique, 26 competencies and 91 interventions were isolated. Cronbach's α was 0.96. Factor analysis yielded 18 factors that explained 68.82% of the variance. Overall inter-item correlation was 0.26, and total-item correlation ranged between 0.66 and 0.19. A competency system for the nursing practicum, structured on the NIC, is a reliable method for assessing and evaluating clinical competencies. Further evaluations in other contexts are needed. The availability of standardized language systems in the nursing discipline supposes an ideal framework to develop the nursing curricula. © 2015 Sigma Theta Tau International.

Stories and Music for Adolescent/Young Adult Resilience During Transplant Partnerships: Strategies to Support Academic-Clinical Nurse Collaborations in Behavioral Intervention Studies.

PubMed

Hendricks-Ferguson, Verna L; Barnes, Yvonne J; Cherven, Brooke; Stegenga, Kristin; Roll, Lona; Docherty, Sharon L; Haase, Joan E

Evidence-based nursing is in the forefront of healthcare delivery systems. Federal and state agencies, academic institutions, and healthcare delivery systems recognize the importance of nursing research. This article describes the mechanisms that facilitate nursing partnerships yielding high-level research outcomes in a clinical setting. A phase-II multicenter behavioral intervention study with pediatric stem cell transplant patients was the context of this academic/clinical research partnership. Strategies to develop and maintain this partnership involved a thorough understanding of each nurse's focus and barriers. A variety of communication plans and training events maximized preexisting professional networks. Academic/clinical nurses' discussions identified barriers to the research process, the most significant being role conflict. Communication and validation of benefits to each individual and institution facilitated the research process during challenging times. Establishing strong academic/clinical partnerships should lead to evidence-based research outcomes for the nursing profession, healthcare delivery systems, and patients and families.

Babies Living Safe & Smokefree: randomized controlled trial of a multilevel multimodal behavioral intervention to reduce low-income children's tobacco smoke exposure.

PubMed

Collins, Bradley N; Lepore, Stephen J

2017-03-14

Addressing children's tobacco smoke exposure (TSE) remains a public health priority. However, there is low uptake and ineffectiveness of treatment, particularly in low-income populations that face numerous challenges to smoking behavior change. A multilevel intervention combining system-level health messaging and advice about TSE delivered at community clinics that disseminate the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), combined with nicotine replacement and intensive multimodal, individual-level behavioral intervention may improve TSE control efforts in such high-risk populations. This trial uses a randomized two-group design with three measurement points: baseline, 3-month and 12-month follow-up. The primary outcome is bioverified child TSE; the secondary outcome is bioverified maternal quit status. Smoking mothers of children less than 6 years old are recruited from WIC clinics. All participants receive WIC system-level intervention based on the "Ask, Advise, Refer (AAR)" best practices guidelines for pediatrics clinics. It includes training all WIC staff about the importance of maternal tobacco control; and detailing clinics with AAR intervention prompts in routine work flow to remind WIC nutrition counselors to ask all mothers about child TSE, advise about TSE harms and benefits of protection, and refer smokers to cessation services. After receiving the system intervention, mothers are randomized to receive 3 months of additional treatment or an attention control intervention: (1) The multimodal behavioral intervention (MBI) treatment includes telephone counseling sessions about child TSE reduction and smoking cessation, provision of nicotine replacement therapy, a mobile app to support cessation efforts, and multimedia text messages about TSE and smoking cessation; (2) The attention control intervention offers equivalent contact as the MBI and includes nutrition-focused telephone counseling, mobile app, and multimedia text messages about improving nutrition. The control condition also receives a referral to the state smoking cessation quitline. This study tests an innovative community-based, multilevel and integrated multimodal approach to reducing child TSE in a vulnerable, low-income population. The approach is sustainable and has potential for wide reach because WIC can integrate the tobacco intervention prompts into routine workflow and refer smokers to free evidence-based behavioral counseling interventions, such as state quitlines. Clinicaltrials.gov NCT02602288 . Registered 9 November 2015.

Real-time MRI guidance of cardiac interventions.

PubMed

Campbell-Washburn, Adrienne E; Tavallaei, Mohammad A; Pop, Mihaela; Grant, Elena K; Chubb, Henry; Rhode, Kawal; Wright, Graham A

2017-10-01

Cardiac magnetic resonance imaging (MRI) is appealing to guide complex cardiac procedures because it is ionizing radiation-free and offers flexible soft-tissue contrast. Interventional cardiac MR promises to improve existing procedures and enable new ones for complex arrhythmias, as well as congenital and structural heart disease. Guiding invasive procedures demands faster image acquisition, reconstruction and analysis, as well as intuitive intraprocedural display of imaging data. Standard cardiac MR techniques such as 3D anatomical imaging, cardiac function and flow, parameter mapping, and late-gadolinium enhancement can be used to gather valuable clinical data at various procedural stages. Rapid intraprocedural image analysis can extract and highlight critical information about interventional targets and outcomes. In some cases, real-time interactive imaging is used to provide a continuous stream of images displayed to interventionalists for dynamic device navigation. Alternatively, devices are navigated relative to a roadmap of major cardiac structures generated through fast segmentation and registration. Interventional devices can be visualized and tracked throughout a procedure with specialized imaging methods. In a clinical setting, advanced imaging must be integrated with other clinical tools and patient data. In order to perform these complex procedures, interventional cardiac MR relies on customized equipment, such as interactive imaging environments, in-room image display, audio communication, hemodynamic monitoring and recording systems, and electroanatomical mapping and ablation systems. Operating in this sophisticated environment requires coordination and planning. This review provides an overview of the imaging technology used in MRI-guided cardiac interventions. Specifically, this review outlines clinical targets, standard image acquisition and analysis tools, and the integration of these tools into clinical workflow. 1 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2017;46:935-950. © 2017 International Society for Magnetic Resonance in Medicine.

Obstacles to Successful Implementation of eHealth Applications into Clinical Practice.

PubMed

Voogt, Marianne P; Opmeer, Brent C; Kastelein, Arnoud W; Jaspers, Monique W M; Peute, Linda W

2018-01-01

eHealth can improve healthcare worldwide, and scientific research should provide evidence on the efficacy, safety and added value of such interventions. For successful implementation of eHealth interventions into clinical practice, barriers need to be anticipated. We identified seven barriers by interviewing health professionals in the Dutch healthcare system. These barriers covered three topics: financing, human factors and organizational factors. This paper discusses their potential impact on eHealth uptake. Bridging the gap between studies to assess effective eHealth interventions and their value-based implementation in healthcare is much needed.

Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI·i project).

PubMed

Aragonès, Enric; Palao, Diego; López-Cortacans, Germán; Caballero, Antonia; Cardoner, Narcís; Casaus, Pilar; Cavero, Myriam; Monreal, José Antonio; Pérez-Sola, Víctor; Cirera, Miquel; Loren, Maite; Bellerino, Eva; Tomé-Pires, Catarina; Palacios, Laura

2017-12-13

Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice. Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care. A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system. The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia). The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework. Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact. This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society. ClinicalTrials.gov identifier: NCT03285659 ; Registered 12th September, 2017.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol.

PubMed

Kestler, Edgar; Walker, Dilys; Bonvecchio, Anabelle; de Tejada, Sandra Sáenz; Donner, Allan

2013-03-21

Maternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries. A matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries. A unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes. ClinicalTrial.gov,http://NCT01653626.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol

PubMed Central

2013-01-01

Background Maternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries. Methods/Design A matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries. Discussion A unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes. Trial registration ClinicalTrial.gov,http://NCT01653626. PMID:23517050

The anatomy of decision support during inpatient care provider order entry (CPOE): Empirical observations from a decade of CPOE experience at Vanderbilt

PubMed Central

Miller, Randolph A.; Waitman, Lemuel R.; Chen, Sutin; Rosenbloom, S. Trent

2006-01-01

The authors describe a pragmatic approach to the introduction of clinical decision support at the point of care, based on a decade of experience in developing and evolving Vanderbilt’s inpatient “WizOrder” care provider order entry (CPOE) system. The inpatient care setting provides a unique opportunity to interject CPOE-based decision support features that restructure clinical workflows, deliver focused relevant educational materials, and influence how care is delivered to patients. From their empirical observations, the authors have developed a generic model for decision support within inpatient CPOE systems. They believe that the model’s utility extends beyond Vanderbilt, because it is based on characteristics of end-user workflows and on decision support considerations that are common to a variety of inpatient settings and CPOE systems. The specific approach to implementing a given clinical decision support feature within a CPOE system should involve evaluation along three axes: what type of intervention to create (for which the authors describe 4 general categories); when to introduce the intervention into the user’s workflow (for which the authors present 7 categories), and how disruptive, during use of the system, the intervention might be to end-users’ workflows (for which the authors describe 6 categories). Framing decision support in this manner may help both developers and clinical end-users plan future alterations to their systems when needs for new decision support features arise. PMID:16290243

Effects of reflection on clinical decision-making of intensive care unit nurses.

PubMed

Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani

2018-07-01

Nurses are one of the most influential factors in overcoming the main challenges faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. This study evaluated the effects of implementing Tanner's reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). This study used an experimental, pretest, posttest design. The setting was the intensive care unit of Amin Hospital Isfahan, Iran. The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-14). The questionnaire was completed before and one week after the intervention. The data were analyzed using SPSS 21.0. The two groups were not significantly different in terms of the level and mean scores of clinical decision-making before the intervention (P = 0.786). Based on the results of independent t-test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann Whitney test showed that one week after the intervention, the nurses' level of clinical decision-making in the case group rose to the next level (P = 0.001). Reflection could improve the clinical decision-making of ICU nurses. It is, thus, recommended to incorporate this method into the nursing curriculum and care practices. Copyright © 2018. Published by Elsevier Ltd.

Clinical leadership development requires system-wide interventions, not just courses.

PubMed

Swanwick, Tim; McKimm, Judy

2012-04-01

This is the third article in a series on clinical leadership and medical education. In the first two articles in this series we looked at the nature of leadership and examined professional outcomes, standards and competency frameworks from around the world that describe what it is we are trying to instil in medical students and doctors in postgraduate training. In this article we explore current trends in leadership development and describe broad approaches to clinical leadership development, highlighting those strategies that are likely to be more (or less) successful. Narrative review and discussion. Key trends and principles for best practice in leadership development are identified. Recommendations for the design of leadership development programmes are made alongside suggestions for system-wide interventions. Leadership development should be both drawn from and embedded in work-based activities, and as far as possible linked to the development of the organisation as a whole. Intervening at the level of the individual may not be enough. System-wide interventions are required that actively engage students and trainees in the practices of management and leadership, and involve them early. © Blackwell Publishing Ltd 2012.

Effective interventions on service quality improvement in a physiotherapy clinic.

PubMed

Gharibi, Farid; Tabrizi, JafarSadegh; Eteraf Oskouei, MirAli; AsghariJafarabadi, Mohammad

2014-01-01

Service quality is considered as a main domain of quality associ-ated with non-clinical aspect of healthcare. This study aimed to survey and im-proves service quality of delivered care in the Physiotherapy Clinic affiliated with the Tabriz University of Medical Sciences, Tabriz, Iran. A quasi experimental interventional study was conducted in the Physiotherapy Clinic, 2010-2011. Data were collected using a validated and reli-able researcher made questionnaire with participation of 324 patients and their coadjutors. The study questionnaire consisted of 7 questions about demographic factors and 38 questions for eleven aspects of service quality. Data were then analyzed using paired samples t-test by SPSS16. In the pre intervention phase, six aspects of service quality including choice of provider, safety, prevention and early detection, dignity, autonomy and availability achieved non-acceptable scores. Following interventions, all aspects of the service quality improved and also total service quality score improved from 8.58 to 9.83 (P<0.001). Service quality can be improved by problem implementation of appropriate interventions. The acquired results can be used in health system fields to create respectful environments for healthcare customers.

Clinical Trials Infrastructure as a Quality Improvement Intervention in Low- and Middle-Income Countries.

PubMed

Denburg, Avram; Rodriguez-Galindo, Carlos; Joffe, Steven

2016-06-01

Mounting evidence suggests that participation in clinical trials confers neither advantage nor disadvantage on those enrolled. Narrow focus on the question of a "trial effect," however, distracts from a broader mechanism by which patients may benefit from ongoing clinical research. We hypothesize that the existence of clinical trials infrastructure-the organizational culture, systems, and expertise that develop as a product of sustained participation in cooperative clinical trials research-may function as a quality improvement lever, improving the quality of care and outcomes of all patients within an institution or region independent of their individual participation in trials. We further contend that this "infrastructure effect" can yield particular benefits for patients in low- and middle-income countries (LMICs). The hypothesis of an infrastructure effect as a quality improvement intervention, if correct, justifies enhanced research capacity in LMIC as a pillar of health system development.

Non-contact tissue perfusion and oxygenation imaging using a LED based multispectral and a thermal imaging system, first results of clinical intervention studies

NASA Astrophysics Data System (ADS)

Klaessens, John H. G. M.; Nelisse, Martin; Verdaasdonk, Rudolf M.; Noordmans, Herke Jan

2013-03-01

During clinical interventions objective and quantitative information of the tissue perfusion, oxygenation or temperature can be useful for the surgical strategy. Local (point) measurements give limited information and affected areas can easily be missed, therefore imaging large areas is required. In this study a LED based multispectral imaging system (MSI, 17 different wavelengths 370nm-880nm) and a thermo camera were applied during clinical interventions: tissue flap transplantations (ENT), local anesthetic block and during open brain surgery (epileptic seizure). The images covered an area of 20x20 cm, when doing measurements in an (operating) room, they turned out to be more complicated than laboratory experiments due to light fluctuations, movement of the patient and limited angle of view. By constantly measuring the background light and the use of a white reference, light fluctuations and movement were corrected. Oxygenation concentration images could be calculated and combined with the thermal images. The effectively of local anesthesia of a hand could be predicted in an early stage using the thermal camera and the reperfusion of transplanted skin flap could be imaged. During brain surgery, a temporary hyper-perfused area was witnessed which was probably related to an epileptic attack. A LED based multispectral imaging system combined with thermal imaging provide complementary information on perfusion and oxygenation changes and are promising techniques for real-time diagnostics during clinical interventions.

A Novel and Intelligent Home Monitoring System for Care Support of Elders with Cognitive Impairment.

PubMed

Lazarou, Ioulietta; Karakostas, Anastasios; Stavropoulos, Thanos G; Tsompanidis, Theodoros; Meditskos, Georgios; Kompatsiaris, Ioannis; Tsolaki, Magda

2016-10-18

Assistive technology, in the form of a smart home environment, is employed to support people with dementia. To propose a system for continuous and objective remote monitoring of problematic daily living activity areas and design personalized interventions based on system feedback and clinical observations for improving cognitive function and health-related quality of life. The assistive technology of the proposed system, including wearable, sleep, object motion, presence, and utility usage sensors, was methodically deployed at four different home installations of people with cognitive impairment. Detection of sleep patterns, physical activity, and activities of daily living, based on the collected sensor data and analytics, was available at all times through comprehensive data visualization solutions. Combined with clinical observation, targeted psychosocial interventions were introduced to enhance the participants' quality of life and improve their cognitive functions and daily functionality. Meanwhile, participants and their caregivers were able to visualize a reduced set of information tailored to their needs. Overall, paired-sample t-test analysis of monitored qualities revealed improvement for all participants in neuropsychological assessment. Moreover, improvement was detected from the beginning to the end of the trial, in physical condition and in the domains of sleep. Detecting abnormalities via the system, for example in sleep quality, such as REM sleep, has proved to be critical to assess current status, drive interventions, and evaluate improvements in a reliable manner. It has been proved that the proposed system is suitable to support clinicians to reliably drive and evaluate clinical interventions toward quality of life improvement of people with cognitive impairment.

Multimodal tissue perfusion imaging using multi-spectral and thermographic imaging systems applied on clinical data

NASA Astrophysics Data System (ADS)

Klaessens, John H. G. M.; Nelisse, Martin; Verdaasdonk, Rudolf M.; Noordmans, Herke Jan

2013-03-01

Clinical interventions can cause changes in tissue perfusion, oxygenation or temperature. Real-time imaging of these phenomena could be useful for surgical strategy or understanding of physiological regulation mechanisms. Two noncontact imaging techniques were applied for imaging of large tissue areas: LED based multispectral imaging (MSI, 17 different wavelengths 370 nm-880 nm) and thermal imaging (7.5 to 13.5 μm). Oxygenation concentration changes were calculated using different analyzing methods. The advantages of these methods are presented for stationary and dynamic applications. Concentration calculations of chromophores in tissue require right choices of wavelengths The effects of different wavelength choices for hemoglobin concentration calculations were studied in laboratory conditions and consequently applied in clinical studies. Corrections for interferences during the clinical registrations (ambient light fluctuations, tissue movements) were performed. The wavelength dependency of the algorithms were studied and wavelength sets with the best results will be presented. The multispectral and thermal imaging systems were applied during clinical intervention studies: reperfusion of tissue flap transplantation (ENT), effectiveness of local anesthetic block and during open brain surgery in patients with epileptic seizures. The LED multispectral imaging system successfully imaged the perfusion and oxygenation changes during clinical interventions. The thermal images show local heat distributions over tissue areas as a result of changes in tissue perfusion. Multispectral imaging and thermal imaging provide complementary information and are promising techniques for real-time diagnostics of physiological processes in medicine.

A simulation model for designing effective interventions in early childhood caries.

PubMed

Hirsch, Gary B; Edelstein, Burton L; Frosh, Marcy; Anselmo, Theresa

2012-01-01

Early childhood caries (ECC)--tooth decay among children younger than 6 years--is prevalent and consequential, affecting nearly half of US 5-year-olds, despite being highly preventable. Various interventions have been explored to limit caries activity leading to cavities, but little is known about the long-term effects and costs of these interventions. We developed a system dynamics model to determine which interventions, singly and in combination, could have the greatest effect in reducing caries experience and cost in a population of children aged birth to 5 years. System dynamics is a computer simulation technique useful to policy makers in choosing the most appropriate interventions for their populations. This study of Colorado preschool children models 6 categories of ECC intervention--applying fluorides, limiting cariogenic bacterial transmission from mothers to children, using xylitol directly with children, clinical treatment, motivational interviewing, and combinations of these--to compare their relative effect and cost. The model projects 10-year intervention costs ranging from $6 million to $245 million and relative reductions in cavity prevalence ranging from none to 79.1% from the baseline. Interventions targeting the youngest children take 2 to 4 years longer to affect the entire population of preschool-age children but ultimately exert a greater benefit in reducing ECC; interventions targeting the highest-risk children provide the greatest return on investment, and combined interventions that target ECC at several stages of its natural history have the greatest potential for cavity reduction. Some interventions save more in dental repair than their cost; all produce substantial reductions in repair cost. By using data relevant to any geographic area, this system model can provide policy makers with information to maximize the return on public health and clinical care investments.

Early Intervention System for Preschool Children with Autism in the Community: The DISCOVERY Approach in Yokohama, Japan.

ERIC Educational Resources Information Center

Honda, Hideo; Shimizu, Yasuo

2002-01-01

This article reports on DISCOVERY, a conceptual model for a clinical system of early detection and early intervention in cases of autism that has been implemented in Yokohama, Japan. Longitudinal data from 49 children who participated in a program during 1987-1990 indicate 32 were still being followed in 1999. (Contains references.) (Author/CR)

Needle and catheter navigation using electromagnetic tracking for computer-assisted C-arm CT interventions

NASA Astrophysics Data System (ADS)

Nagel, Markus; Hoheisel, Martin; Petzold, Ralf; Kalender, Willi A.; Krause, Ulrich H. W.

2007-03-01

Integrated solutions for navigation systems with CT, MR or US systems become more and more popular for medical products. Such solutions improve the medical workflow, reduce hardware, space and costs requirements. The purpose of our project was to develop a new electromagnetic navigation system for interventional radiology which is integrated into C-arm CT systems. The application is focused on minimally invasive percutaneous interventions performed under local anaesthesia. Together with a vacuum-based patient immobilization device and newly developed navigation tools (needles, panels) we developed a safe and fully automatic navigation system. The radiologist can directly start with navigated interventions after loading images without any prior user interaction. The complete system is adapted to the requirements of the radiologist and to the clinical workflow. For evaluation of the navigation system we performed different phantom studies and achieved an average accuracy of better than 2.0 mm.

New Medicine for the U.S. Health Care System: Training Physicians for Structural Interventions.

PubMed

Hansen, Helena; Metzl, Jonathan M

2017-03-01

Structural competency provides a language and theoretical framework to promote institutional-level interventions by clinical practitioners working with community organizations, non-health-sector institutions, and policy makers. The special collection of articles on structural competency in this issue of Academic Medicine addresses the need to move from theory to an appraisal of core educational interventions that operationalize the goals of and foster structural competency. In this Commentary, the authors review the role of clinical practitioners in enhancing population-level health outcomes through collaborations with professionals in fields outside medicine, including the social sciences and law. They describe the core elements of structural competency in preclinical and clinical education, as illustrated by the articles of this special collection: perceiving the structural causes of patients' disease, envisioning structural interventions, and cultivating alliances with non-health-sector agencies that can implement structural interventions. Finally, the authors argue that preparing trainees to form partnerships will empower them to influence the social determinants of their patients' health and reduce health inequalities.

A hybrid image fusion system for endovascular interventions of peripheral artery disease.

PubMed

Lalys, Florent; Favre, Ketty; Villena, Alexandre; Durrmann, Vincent; Colleaux, Mathieu; Lucas, Antoine; Kaladji, Adrien

2018-07-01

Interventional endovascular treatment has become the first line of management in the treatment of peripheral artery disease (PAD). However, contrast and radiation exposure continue to limit the feasibility of these procedures. This paper presents a novel hybrid image fusion system for endovascular intervention of PAD. We present two different roadmapping methods from intra- and pre-interventional imaging that can be used either simultaneously or independently, constituting the navigation system. The navigation system is decomposed into several steps that can be entirely integrated within the procedure workflow without modifying it to benefit from the roadmapping. First, a 2D panorama of the entire peripheral artery system is automatically created based on a sequence of stepping fluoroscopic images acquired during the intra-interventional diagnosis phase. During the interventional phase, the live image can be synchronized on the panorama to form the basis of the image fusion system. Two types of augmented information are then integrated. First, an angiography panorama is proposed to avoid contrast media re-injection. Information exploiting the pre-interventional computed tomography angiography (CTA) is also brought to the surgeon by means of semiautomatic 3D/2D registration on the 2D panorama. Each step of the workflow was independently validated. Experiments for both the 2D panorama creation and the synchronization processes showed very accurate results (errors of 1.24 and [Formula: see text] mm, respectively), similarly to the registration on the 3D CTA (errors of [Formula: see text] mm), with minimal user interaction and very low computation time. First results of an on-going clinical study highlighted its major clinical added value on intraoperative parameters. No image fusion system has been proposed yet for endovascular procedures of PAD in lower extremities. More globally, such a navigation system, combining image fusion from different 2D and 3D image sources, is novel in the field of endovascular procedures.

Clinical services provided by staff pharmacists in a community hospital.

PubMed

Garrelts, J C; Smith, D F

1990-09-01

A program for developing staff pharmacists' clinical skills and documenting pharmacists' clinical interventions in a large community teaching hospital is described. A coordinator hired in 1984 to develop clinical pharmacy services began a didactic and experiential program for baccalaureate-level staff pharmacists. Fourteen educational modules are supplemented by journal and textbook articles and small-group discussions of clinical cases, and the clinical coordinator provides individual training on the patient-care units for each pharmacist. Monitoring of clinical pharmacy services began in June 1987; each intervention provided by a pharmacist is recorded on a specially designed form. A target-drug program is used to document cost avoidance achieved through clinical services. Information collected through these monitoring activities is used to educate the pharmacy staff, shared with the pharmacy and therapeutics committee, and used to monitor prescribing patterns of individual physicians. The data are used in the hospital's productivity-monitoring system. All pharmacists who were on staff in 1984 have completed the educational modules, and all new employees are in the process. Since monitoring began, the number of clinical interventions has averaged 2098 per month. Cost avoidance has averaged $9306 per month. Over a five-year period, the development of staff pharmacists' clinical services raised the level of professional practice, produced substantial cost avoidance, and increased the number of pharmacist interventions in medication use.

Human Papillomavirus Vaccine Coverage and Prevalence of Missed Opportunities for Vaccination in an Integrated Healthcare System.

PubMed

Irving, Stephanie A; Groom, Holly C; Stokley, Shannon; McNeil, Michael M; Gee, Julianne; Smith, Ning; Naleway, Allison L

2018-03-01

Human papillomavirus (HPV) vaccination has been recommended in the United States for female and male adolescents since 2006 and 2011, respectively. Coverage rates are lower than those for other adolescent vaccines. The objective of this study was to evaluate an assessment and feedback intervention designed to increase HPV vaccination coverage and quantify missed opportunities for HPV vaccine initiation at preventive care visits. We examined changes in HPV vaccination coverage and missed opportunities within the adolescent (11-17 years) population at 9 Oregon-based Kaiser Permanente Northwest outpatient clinics after an assessment and feedback intervention. Quarterly coverage rates were calculated for the adolescent populations at the clinics, according to age group (11-12 and 13-17 years), sex, and department (Pediatrics and Family Medicine). Comparison coverage assessments were calculated at 3 nonintervention (control) clinics. Missed opportunities for HPV vaccine initiation, defined as preventive care visits in which a patient eligible for HPV dose 1 remained unvaccinated, were examined according to sex and age group. An average of 29,021 adolescents were included in coverage assessments. Before the intervention, 1-dose and 3-dose quarterly coverage rates were increasing at intervention as well as at control clinics in both age groups. Postimplementation quarterly trends in 1-dose or 3-dose coverage did not differ significantly between intervention and control clinics for either age group. One-dose coverage rates among adolescents with Pediatrics providers were significantly higher than those with Family Medicine providers (56% vs 41% for 11- to 12-year-old and 82% vs 69% for 13- to 17-year-old girls; 55% vs 40% for 11- to 12-year-old and 78% vs 62% for 13- to 17-year-old boys). No significant differences in HPV vaccine coverage were identified at intervention clinics. However, coverage rates were increasing before the start of the intervention and might have been influenced by ongoing health system best practices. HPV vaccine coverage rates varied significantly according to department, which could allow for targeted improvement opportunities. Copyright © 2017 Academic Pediatric Association. All rights reserved.

Innovations in adult influenza vaccination in China, 2014-2015: Leveraging a chronic disease management system in a community-based intervention.

PubMed

Yi, Bo; Zhou, Suizan; Song, Ying; Chen, Enfu; Lao, Xuyin; Cai, Jian; Greene, Carolyn M; Feng, Luzhao; Zheng, Jiandong; Yu, Hongjie; Dong, Hongjun

2018-04-03

To evaluate a community-based intervention that leveraged the non-communicable disease management system to increase seasonal influenza vaccination coverage among older adults in Ningbo, China. From October 2014 - March 2015, we piloted the following on one street in Ningbo, China: educating community healthcare workers (C-HCWs) about influenza and vaccination; requiring C-HCWs to recommend influenza vaccination to older adults during routine chronic disease follow-up; and opening 14 additional temporary vaccination clinics. We selected a non-intervention street for comparison pre- and post-intervention vaccine coverage. In April 2016, we interviewed a random sample of unvaccinated older adults on the intervention street to ask why they remained unvaccinated. Pre-intervention influenza vaccine coverage among adults aged 60 years and older on both streets was 0.3%. Post-intervention, coverage among adults 60 years and older was 19% (1338/7013) on the intervention street and 0.4% (20/5500) on the non-intervention street (p<0.01). Among vaccinated older adults, 98% reported their main reason for vaccination was receiving a C-HCW's recommendation, 90% were vaccinated at temporary vaccination clinics, and 53% paid for vaccine (10 USD) out-of-pocket. Reasons for not getting vaccinated among 150 unvaccinated adults (response rate = 75%) included: good health (39%); not trusting C-HCWs' recommendations (24%); not knowing where to get vaccinated (17%); and not wanting to pay (9%). Recommending influenza vaccination within a non-communicable disease management system, combined with adding vaccination sites, increased vaccine coverage among older adults in Ningbo, China.

A family systems nursing intervention model for paediatric health crisis.

PubMed

Tomlinson, Patricia Short; Peden-McAlpine, Cynthia; Sherman, Suzan

2012-03-01

This article discusses the development of a family systems nursing intervention for clinical use in health crisis. Although studies in paediatric critical care provide evidence that family stress is an important clinical phenomenon, studies have demonstrated that few nurses have the requisite family intervention skills to provide family members with adequate support during crisis. In addition, few intervention studies that focus on provider-family relationships with the goal of reducing stress have been reported. This article contributes to the literature by redressing this lack. Data sources.  The literature search supporting this project spanned from 1980 to 2009 and included searches from classic nursing theory, family theory and relevant nursing research specific to the design of the intervention reported. The goal of the intervention is to provide a theoretical and practical foundation for explicit action that enhances relationships with caregivers thereby supporting the integrity of the family and enhancing their coping abilities. The intervention, based on the Family Systems Model and the family's understandings of the situation, defines specific goals and desired outcomes to guide strategic actions. Discussion of the conceptual foundation, procedural development and an example of the protocol is provided. Implications for nursing.  The intervention is designed for nurses with limited knowledge in family theory to aid them to better help families dealing with stress. The proposed intervention can be used to increase nurses' skills in family centred nursing care. Although designed for use in paediatric critical care, it can, with modifications, be used in other nursing specialty areas. © 2011 Blackwell Publishing Ltd.

Music intervention as system: reversing hyper systemising in autism spectrum disorders to the comprehension of music as intervention.

PubMed

Jaschke, Artur C

2014-01-01

This paper seeks to combine the notion of the Empathising-Systemising (E-S) theory and the resulting twist from the executive dysfunction theory in autism spectrum conditions (ASC) in light of music intervention as system. To achieve these points it will be important to re-visit, nonetheless briefly, the above mentioned theories and re-define music intervention in the light of these. Furthermore there is the need to adjust the executive dysfunction theory to a theory of dysfunctioning executive functions. These notions will create a different understanding of music intervention in this context, allowing the development of future and existing music intervention programs applied clinically. These applications will evolve around a structuralised approach to music intervention as system, proposing five consecutive systems. It will therefore argue the aspects of expanding existing theories in ASC together with the call for generalised interventions to better assess autism from a theoretical point of view. Theories have to be updated in a time of fast and ever-changing development. Copyright © 2013 Elsevier Ltd. All rights reserved.

Self-management support interventions that are clinically linked and technology enabled: can they successfully prevent and treat diabetes?

PubMed

Kaufman, Neal D; Woodley, Paula D Patnoe

2011-05-01

Patients with diabetes need a complex set of services and supports. The challenge of integrating these services into the diabetes regimen can be successfully overcome through self-management support interventions that are clinically linked and technology enabled: self-management support because patients need help mastering the knowledge, attitudes, skills, and behaviors so necessary for good outcomes; interventions because comprehensive theory-based, evidence-proven, long-term, longitudinal interventions work better than direct-to-consumer or nonplanned health promotion approaches; clinically linked because patients are more likely to adopt new behaviors when the approach is in the context of a trusted therapeutic relationship and within an effective medical care system; and technology enabled because capitalizing on the amazing power of information technology leads to the delivery of cost-effective, scalable, engaging solutions that prevent and manage diabetes. © 2011 Diabetes Technology Society.

Detroit's avoidable mortality project: breast cancer control for inner-city women.

PubMed Central

Burack, R C; Gimotty, P A; Stengle, W; Eckert, D; Warbasse, L; Moncrease, A

1989-01-01

Mammography remains substantially under-used in low-income minority populations despite its well-established efficacy as a means of breast cancer control. The Metropolitan Detroit Avoidable Mortality Project is a 2-year controlled clinical trial of coordinated interventions which seek to improve the use of early breast cancer detection services at five clinical sites providing primary health care services to inner-city women. Baseline assessment for two of the five participating clinic populations demonstrated that only one-quarter of women who visited these clinics were referred for mammography in 1988, and only half of those who were referred were able to complete the procedure. Patient characteristics including age, marital status, ethnicity, and insurance status were not associated with use of mammography during the baseline period. Each of the project's intervention components is a cue to action: a physician prompt for mammography referral within the medical record of procedure-due women, a reminder postcard for scheduled appointments, and a telephone call to encourage rescheduling of missed appointments. The interventions are initiated by a computerized information management system in the existing network of health care services. The patient's out-of-pocket mammography expense has been eliminated in three of the five sites. Although their efficacy as individual interventions has been well established, a controlled trial of computer prompts to physicians, reduced expense for patients, and patient appointment reminders as an integrated system in inner-city medical care settings has not been previously described. We have implemented the prompting, facilitated rescheduling procedures, and eliminated patient expense for mammography at three of five eventual clinical sites. This report provides an overview of the study's design, data management system, and methodology for evaluation. PMID:2511584

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial.

PubMed

Yotebieng, Marcel; Behets, Frieda; Kawende, Bienvenu; Ravelomanana, Noro Lantoniaina Rosa; Tabala, Martine; Okitolonda, Emile W

2017-04-26

Despite the rapid adoption of the World Health Organization's 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669 .

Systemic Therapy for Youth at Clinical High Risk for Psychosis: A Pilot Study.

PubMed

Shi, Jingyu; Wang, Lu; Yao, Yuhong; Zhan, Chenyu; Su, Na; Zhao, Xudong

2017-01-01

Psychosocial intervention trials for youth at clinical high risk (CHR) for psychosis have shown promising effects on treating psychotic symptoms but have not focused on psychosocial functional outcomes, and those studies have been conducted among help-seeking patients; there is a lack of research on non-clinical young CHR individuals. Systemic therapy (ST) is grounded in systemic-constructivist and psychosocial resilience theories. It has a number of advantages that makes it attractive for use with CHR individuals in non-clinical context. The present study evaluated the effect of ST for students at CHR on reducing symptoms and enhancing psychosocial function. This was a single-blind randomized controlled trial for CHR young people comparing ST to supportive therapy with a 6-month treatment. Psychotic and depressive symptoms (DS) as well as self-esteem and social support (SS) were assessed at pre- and posttreatment. 26 CHR individuals were randomly divided into intervention group ( n  = 13) and control group ( n  = 13). There were no significant differences in severity of symptoms, level of SS and self-esteem at baseline between the two groups ( P  > 0.05). At posttreatment, significant improvements in positive and DS as well as SS and self-esteem were observed in the ST group ( P  < 0.05); in the control group, these improvements were not significant ( P  > 0.05). The findings indicated that systemic intervention for university students at CHR for psychosis may have a positive effect on symptoms and self-esteem as well as SS in short term. More long-term research is needed to further evaluate this intervention.

Accelerating Maternal and Child Health Gains in Papua New Guinea: Modelled Predictions from Closing the Equity Gap Using LiST.

PubMed

Byrne, Abbey; Hodge, Andrew; Jimenez-Soto, Eliana

2015-11-01

Many priority countries in the countdown to the millennium development goals deadline are lagging in progress towards maternal and child health (MCH) targets. Papua New Guinea (PNG) is one such country beset by challenges of geographical inaccessibility, inequity and health system weakness. Several countries, however, have made progress through focused initiatives which align with the burden of disease and overcome specific inequities. This study identifies the potential impact on maternal and child mortality through increased coverage of prioritised interventions within the PNG health system. The burden of disease and health system environment of PNG was documented to inform prioritised MCH interventions at community, outreach, and clinical levels. Potential reductions in maternal and child mortality through increased intervention coverage to close the geographical equity gap were estimated with the lives saved tool. A set community-level interventions, with highest feasibility, would yield significant reductions in newborn and child mortality. Adding the outreach group delivers gains for maternal mortality, particularly through family planning. The clinical services group of interventions demands greater investment but are essential to reach MCH targets. Cumulatively, the increased coverage is estimated to reduce the rates of under-five mortality by 19 %, neonatal mortality by 26 %, maternal mortality ratio by 10 % and maternal mortality by 33 %. Modest investments in health systems focused on disadvantaged populations can accelerate progress in maternal and child survival even in fragile health systems like PNG. The critical approach may be to target interventions and implementation appropriately to the sensitive context of lagging countries.

Antimicrobial stewardship programs: interventions and associated outcomes.

PubMed

Patel, Dimple; Lawson, Wendy; Guglielmo, B Joseph

2008-04-01

Guidelines regarding antimicrobial stewardship programs recommend an infectious diseases-trained physician and an infectious diseases-trained pharmacist as core members. Inclusion of clinical microbiologists, infection-control practitioners, information systems experts and hospital epidemiologists is considered optimal. Recommended stewardship interventions include prospective audit and intervention, formulary restriction, education, guideline development, clinical pathway development, antimicrobial order forms and the de-escalation of therapy. The primary outcome associated with these interventions has been the associated cost savings; however, few published investigations have taken into account the overall cost of the intervention. Over the past 5 years, there has been an increased focus upon interventions intended to decrease bacterial resistance or reduce superinfection, including infections associated with Clostridium difficile colitis. Few programs have been associated with a reduction in antimicrobial drug adverse events. Antimicrobial stewardship programs are becoming increasingly associated with clear benefits and will be integral in the in-patient healthcare setting.

Redesign of a university hospital preanesthesia evaluation clinic using a queuing theory approach.

PubMed

Zonderland, Maartje E; Boer, Fredrik; Boucherie, Richard J; de Roode, Annemiek; van Kleef, Jack W

2009-11-01

Changes in patient length of stay (the duration of 1 clinic visit) as a result of the introduction of an electronic patient file system forced an anesthesia department to change its outpatient clinic organization. In this study, we sought to demonstrate how the involvement of essential employees combined with mathematical techniques to support the decision-making process resulted in a successful intervention. The setting is the preanesthesia evaluation clinic (PAC) of a university hospital, where patients consult several medical professionals, either by walk-in or appointment. Queuing theory was used to model the initial set-up of the clinic, and later to model possible alternative designs. With the queuing model, possible improvements in efficiency could be investigated. Inputs to the model were patient arrival rates and expected service times with clinic employees, collected from the clinic's logging system and by observation. The performance measures calculated with the model were patient length of stay and employee utilization rate. Supported by the model outcomes, a working group consisting of representatives of all clinic employees decided whether the initial design should be maintained or an intervention was needed. The queuing model predicted that 3 of the proposed alternatives would result in better performance. Key points in the intervention were the rescheduling of appointments and the reallocation of tasks. The intervention resulted in a shortening of the time the anesthesiologist needed to decide upon approving the patient for surgery. Patient arrivals increased sharply over 1 yr by more than 16%; however, patient length of stay at the clinic remained essentially unchanged. If the initial set-up of the clinic would have been maintained, the patient length of stay would have increased dramatically. Queuing theory provides robust methods to evaluate alternative designs for the organization of PACs. In this article, we show that queuing modeling is an adequate approach for redesigning processes in PACs.

Promoting Tobacco Use Cessation for Lesbian, Gay, Bisexual, and Transgender People

PubMed Central

Lee, Joseph G. L.; Matthews, Alicia K.; McCullen, Cramer A.; Melvin, Cathy L.

2014-01-01

Context Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of gray and peer-reviewed literature describing clinical, community, and policy interventions as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people. Evidence acquisition Eight databases for articles from 1987 to April 23, 2014 were searched. In February–November 2013, authors and researchers were contacted to identify gray literature. Evidence synthesis The search identified 57 records, of which 51 were relevant and 22 were from the gray literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October–May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities; although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting messaging used in media campaigns. Conclusions LGBT-serving organizations should implement existing evidence-based tobacco dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions. PMID:25455123

Evaluating the effect of a web-based quality improvement system with feedback and outreach visits on guideline concordance in the field of cardiac rehabilitation: rationale and study protocol.

PubMed

van Engen-Verheul, Mariëtte M; de Keizer, Nicolette F; van der Veer, Sabine N; Kemps, Hareld M C; Scholte op Reimer, Wilma J M; Jaspers, Monique W M; Peek, Niels

2014-12-31

Implementation of clinical practice guidelines into daily care is hampered by a variety of barriers related to professional knowledge and collaboration in teams and organizations. To improve guideline concordance by changing the clinical decision-making behavior of professionals, computerized decision support (CDS) has been shown to be one of the most effective instruments. However, to address barriers at the organizational level, additional interventions are needed. Continuous monitoring and systematic improvement of quality are increasingly used to achieve change at this level in complex health care systems. The study aims to assess the effectiveness of a web-based quality improvement (QI) system with indicator-based performance feedback and educational outreach visits to overcome organizational barriers for guideline concordance in multidisciplinary teams in the field of cardiac rehabilitation (CR). A multicenter cluster-randomized trial with a balanced incomplete block design will be conducted in 18 Dutch CR clinics using an electronic patient record with CDS at the point of care. The intervention consists of (i) periodic performance feedback on quality indicators for CR and (ii) educational outreach visits to support local multidisciplinary QI teams focussing on systematically improving the care they provide. The intervention is supported by a web-based system which provides an overview of the feedback and facilitates development and monitoring of local QI plans. The primary outcome will be concordance to national CR guidelines with respect to the CR needs assessment and therapy indication procedure. Secondary outcomes are changes in performance of CR clinics as measured by structure, process and outcome indicators, and changes in practice variation on these indicators. We will also conduct a qualitative process evaluation (concept-mapping methodology) to assess experiences from participating CR clinics and to gain insight into factors which influence the implementation of the intervention. To our knowledge, this will be the first study to evaluate the effect of providing performance feedback with a web-based system that incorporates underlying QI concepts. The results may contribute to improving CR in the Netherlands, increasing knowledge on facilitators of guideline implementation in multidisciplinary health care teams and identifying success factors of multifaceted feedback interventions. NTR3251.

Vascular Access Tracking System: a Web-Based Clinical Tracking Tool for Identifying Catheter Related Blood Stream Infections in Interventional Radiology Placed Central Venous Catheters.

PubMed

Morrison, James; Kaufman, John

2016-12-01

Vascular access is invaluable in the treatment of hospitalized patients. Central venous catheters provide a durable and long-term solution while saving patients from repeated needle sticks for peripheral IVs and blood draws. The initial catheter placement procedure and long-term catheter usage place patients at risk for infection. The goal of this project was to develop a system to track and evaluate central line-associated blood stream infections related to interventional radiology placement of central venous catheters. A customized web-based clinical database was developed via open-source tools to provide a dashboard for data mining and analysis of the catheter placement and infection information. Preliminary results were gathered over a 4-month period confirming the utility of the system. The tools and methodology employed to develop the vascular access tracking system could be easily tailored to other clinical scenarios to assist in quality control and improvement programs.

Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach.

PubMed

Mukumbang, Ferdinand C; Marchal, Bruno; Van Belle, Sara; van Wyk, Brian

2018-05-09

Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing intervention to enhance the retention in care of patients on ART and their adherence to medication. Although empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health system contexts the adherence club intervention works (or not). We undertook a realist evaluation study to uncover the programme theory of the adherence club intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes of the adherence club intervention, guided by retroductive inferencing. We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when required works because patients' self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility and the community. Understanding what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, could inform guidelines for effective implementation in different contexts and scaling up of the intervention to improve population-level ART adherence.

The Technology Acceptance Model for Resource-Limited Settings (TAM-RLS): A Novel Framework for Mobile Health Interventions Targeted to Low-Literacy End-Users in Resource-Limited Settings.

PubMed

Campbell, Jeffrey I; Aturinda, Isaac; Mwesigwa, Evans; Burns, Bridget; Santorino, Data; Haberer, Jessica E; Bangsberg, David R; Holden, Richard J; Ware, Norma C; Siedner, Mark J

2017-11-01

Although mobile health (mHealth) technologies have shown promise in improving clinical care in resource-limited settings (RLS), they are infrequently brought to scale. One limitation to the success of many mHealth interventions is inattention to end-user acceptability, which is an important predictor of technology adoption. We conducted in-depth interviews with 43 people living with HIV in rural Uganda who had participated in a clinical trial of a short messaging system (SMS)-based intervention designed to prompt return to clinic after an abnormal laboratory test. Interviews focused on established features of technology acceptance models, including perceived ease of use and perceived usefulness, and included open-ended questions to gain insight into unexplored issues related to the intervention's acceptability. We used conventional (inductive) and direct content analysis to derive categories describing use behaviors and acceptability. Interviews guided development of a proposed conceptual framework, the technology acceptance model for resource-limited settings (TAM-RLS). This framework incorporates both classic technology acceptance model categories as well as novel factors affecting use in this setting. Participants described how SMS message language, phone characteristics, and experience with similar technologies contributed to the system's ease of use. Perceived usefulness was shaped by the perception that the system led to augmented HIV care services and improved access to social support from family and colleagues. Emergent themes specifically related to mHealth acceptance among PLWH in Uganda included (1) the importance of confidentiality, disclosure, and stigma, and (2) the barriers and facilitators downstream from the intervention that impacted achievement of the system's target outcome. The TAM-RLS is a proposed model of mHealth technology acceptance based upon end-user experiences in rural Uganda. Although the proposed model requires validation, the TAM-RLS may serve as a useful tool to guide design and implementation of mHealth interventions.

Patient reminder systems and asthma medication adherence: a systematic review.

PubMed

Tran, Nancy; Coffman, Janet M; Sumino, Kaharu; Cabana, Michael D

2014-06-01

One of the most common reasons for medication non-adherence for asthma patients is forgetfulness. Daily medication reminder system interventions in the form of text messages, automated phone calls and audiovisual reminder devices can potentially address this problem. The aim of this review was to assess the effectiveness of reminder systems on patient daily asthma medication adherence. We conducted a systematic review of the literature to identify randomized controlled trials (RCTs) which assessed the effect of reminder systems on daily asthma medication adherence. We searched all English-language articles in Pub Med (MEDLINE), CINAHL, EMBASE, PsychINFO and the Cochrane Library through May 2013. We abstracted data on the year of study publication, location, inclusion and exclusion criteria, patient characteristics, reminder system characteristics, effect on patient adherence rate and other outcomes measured. Descriptive statistics were used to summarize the characteristics and results of the studies. Five RCTs and one pragmatic RCT were included in the analysis. Median follow-up time was 16 weeks. All of the six studies suggested that the reminder system intervention was associated with greater levels of participant asthma medication adherence compared to those participants in the control group. None of the studies documented a change in asthma-related quality of life or clinical asthma outcomes. All studies in our analysis suggest that reminder systems increase patient medication adherence, but none documented improved clinical outcomes. Further studies with longer intervention durations are needed to assess effects on clinical outcomes, as well as the sustainability of effects on patient adherence.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice.

PubMed

Sharp, Carla; Fonagy, Peter

2015-12-01

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners. In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents. Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings. © 2015 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

Interventional Oncology in Hepatocellular Carcinoma: Progress Through Innovation.

PubMed

Mu, Lin; Chapiro, Julius; Stringam, Jeremiah; Geschwind, Jean-François

The clinical management of hepatocellular carcinoma has evolved greatly in the last decade mostly through recent technical innovations. In particular, the application of cutting-edge image guidance has led to minimally invasive solutions for complex clinical problems and rapid advances in the field of interventional oncology. Many image-guided therapies, such as transarterial chemoembolization and radiofrequency ablation, have meanwhile been fully integrated into interdisciplinary clinical practice, whereas others are currently being investigated. This review summarizes and evaluates the most relevant completed and ongoing clinical trials, provides a synopsis of recent innovations in the field of intraprocedural imaging and tumor response assessment, and offers an outlook on new technologies, such as radiopaque embolic materials. In addition, combination therapies consisting of locoregional therapies and systemic molecular targeted agents (e.g., sorafenib) remain of major interest to the field and are also discussed. Finally, we address the many substantial advances in immune response pathways that have been related to the systemic effects of locoregional therapies. Knowledge of these new developments is crucial as they continue to shape the future of cancer treatment, further establishing interventional oncology along with surgical, medical, and radiation oncology as the fourth pillar of cancer care.

Emergency department-based interventions for women suffering domestic abuse: a critical literature review.

PubMed

Ansari, Sereena; Boyle, Adrian

2017-02-01

Domestic abuse represents a serious public health and human rights concern. Interventions to reduce the risk of abuse include staff training and standardized documentation improving detection and adherence to referral pathways. Interventional studies have been conducted in primary care, maternity and outpatient settings. Women disclosing abuse in emergency departments differ from women attending other healthcare settings, and it is unclear whether these interventions can be transferred to the emergency care setting. This review examines interventional studies to evaluate the effectiveness of emergency department-based interventions in reducing domestic abuse-related morbidity. Medline, EMBASE, CINAHL, PsycINFO and Cochrane Library were searched, according to prespecified selection criteria. Study quality was assessed using the Jadad scale. Of 273 search results, nine were eligible for review. Interventions involving staff training demonstrated benefits in subjective measures, such as staff knowledge regarding abuse, but no changes in clinical practice, based on detection and referral rates. When staff training was implemented in conjunction with supporting system changes - for example, standardized documentation for assessment and referral - clinically relevant improvements were noted. Interventions centred around staff training are insufficient to bring about improvements in the management and, thus, outcome of patients suffering abuse. Instead, system changes, such as standardized documentation and referral pathways, supported by training, may bring about beneficial changes. It remains uncertain whether surrogate outcomes employed by most studies translate to changes in abuse-related morbidity: the ultimate goal.

Clinical Perspectives from Randomized Phase 3 Trials on Prostate Cancer: An Analysis of the ClinicalTrials.gov Database.

PubMed

Tsikkinis, Alexandros; Cihoric, Nikola; Giannarini, Gianluca; Hinz, Stefan; Briganti, Alberto; Wust, Peter; Ost, Piet; Ploussard, Guillaume; Massard, Christophe; Surcel, Cristian I; Sooriakumaran, Prasanna; Isbarn, Hendrik; De Visschere, Peter J L; Futterer, Jurgen J; van der Bergh, Roderick C N; Dal Pra, Alan; Aebersold, Daniel M; Budach, Volker; Ghadjar, Pirus

2015-09-01

It is not easy to overview pending phase 3 trials on prostate cancer (PCa), and awareness of these trials would benefit clinicians. To identify all phase 3 trials on PCa registered in the ClinicalTrials.gov database with pending results. On September 29, 2014, a database was established from the records for 175 538 clinical trials registered on ClinicalTrials.gov. A search of this database for the substring "prostat" identified 2951 prostate trials. Phase 3 trials accounted for 441 studies, of which 333 concerned only PCa. We selected only ongoing or completed trials with pending results, that is, for which the primary endpoint had not been published in a peer-reviewed medical journal. We identified 123 phase 3 trials with pending results. Trials were conducted predominantly in North America (n=63; 51%) and Europe (n=47; 38%). The majority were on nonmetastatic disease (n=82; 67%), with 37 (30%) on metastatic disease and four trials (3%) including both. In terms of intervention, systemic treatment was most commonly tested (n=71; 58%), followed by local treatment 34 (28%), and both systemic and local treatment (n=11; 9%), with seven (6%) trials not classifiable. The 71 trials on systemic treatment included androgen deprivation therapy (n=34; 48%), chemotherapy (n=15; 21%), immunotherapy (n=9; 13%), other systemic drugs (n=9; 13%), radiopharmaceuticals (n=2; 3%), and combinations (n=2; 3%). Local treatments tested included radiation therapy (n=27; 79%), surgery (n=5; 15%), and both (n=2; 2%). A limitation is that not every clinical trial is registered on ClinicalTrials.gov. There are many PCa phase 3 trials with pending results, most of which address questions regarding systemic treatments for both nonmetastatic and metastatic disease. Radiation therapy and androgen deprivation therapy are the interventions most commonly tested for local and systemic treatment, respectively. This report describes all phase 3 trials on prostate cancer registered in the ClinicalTrials.gov database with pending results. Most of these trials address questions regarding systemic treatments for both nonmetastatic and metastatic disease. Radiation therapy and androgen deprivation therapy are the interventions most commonly tested for local and systemic treatment, respectively. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Counterbalancing patient demands with evidence: results from a pan-Canadian randomized clinical trial of brief supportive-expressive group psychotherapy for women with systemic lupus erythematosus.

PubMed

Dobkin, Patricia L; Da Costa, Deborah; Joseph, Lawrence; Fortin, Paul R; Edworthy, Steven; Barr, Susan; Ensworth, Stephanie; Esdaile, John M; Beaulieu, André; Zummer, Michel; Senécal, Jean-Luc; Goulet, Jean-Richard; Choquette, Denis; Rich, Eric; Smith, Doug; Cividino, Alfred; Gladman, Dafna; St-Pierre, Yvan; Clarke, Ann E

2002-01-01

To evaluate the effect of Brief Supportive-Expressive Group Psychotherapy as an adjunct to standard medical care in reducing psychological distress, medical symptoms, and health care costs and improving quality of life in women with systemic lupus erythematosus (SLE). A randomized clinical trial was conducted with 133 SLE female patients from 9 clinics across Canada. Clinical and psychosocial measures were taken at baseline, posttreatment, and 6 and 12 months posttreatment. Outcomes assessed were psychological distress, quality of life, disease activity, health service utilization, and diminished productivity. Intention-to-treat analyses revealed that there were no clinically important group differences on any of the outcome measures. Although both groups improved over time on several measures (e.g., decreases in psychological distress, stress, and emotion-oriented coping), these changes could not be attributed to the psychotherapeutic intervention. Thus, evidence does not support the referral of these patients to this type of intervention.

Clinical Inertia in a Randomized Trial of Telemedicine-Based Chronic Disease Management: Lessons Learned.

PubMed

Barton, Anna Beth; Okorodudu, Daniel E; Bosworth, Hayden B; Crowley, Matthew J

2018-01-17

Treatment nonadherence and clinical inertia perpetuate poor cardiovascular disease (CVD) risk factor control. Telemedicine interventions may counter both treatment nonadherence and clinical inertia. We explored why a telemedicine intervention designed to reduce treatment nonadherence and clinical inertia did not improve CVD risk factor control, despite enhancing treatment adherence versus usual care. In this analysis of a randomized trial, we studied recipients of the 12-month telemedicine intervention. This intervention comprised two nurse-administered components: (1) monthly self-management education targeting improved treatment adherence; and (2) quarterly medication management facilitation designed to support treatment intensification by primary care (thereby reducing clinical inertia). For each medication management facilitation encounter, we ascertained whether patients met treatment goals, and if not, whether primary care recommended treatment intensification following the encounter. We assessed disease control associated with encounters, where intensification was/was not recommended. We examined 455 encounters across 182 intervention recipients (100% African Americans with type 2 diabetes). Even after accounting for valid reasons for deferring intensification (e.g., treatment nonadherence), intensification was not recommended in 67.5% of encounters in which hemoglobin A1c was above goal, 72.5% in which systolic blood pressure was above goal, and 73.9% in which low-density lipoprotein cholesterol was above goal. In each disease state, treatment intensification was more likely with poorer control. Despite enhancing treatment adherence, this intervention was unsuccessful in countering clinical inertia, likely explaining its lack of effect on CVD risk factors. We identify several lessons learned that may benefit investigators and healthcare systems.

Interventions to Improve the Response of Professionals to Children Exposed to Domestic Violence and Abuse: A Systematic Review

PubMed Central

Hester, Marianne; Broad, Jonathan; Szilassy, Eszter; Feder, Gene; Drinkwater, Jessica; Firth, Adam; Stanley, Nicky

2015-01-01

Exposure of children to domestic violence and abuse (DVA) is a form of child maltreatment with short‐ and long‐term behavioural and mental health impact. Health care professionals are generally uncertain about how to respond to domestic violence and are particularly unclear about best practice with regards to children's exposure and their role in a multiagency response. In this systematic review, we report educational and structural or whole‐system interventions that aim to improve professionals' understanding of, and response to, DVA survivors and their children. We searched 22 bibliographic databases and contacted topic experts for studies reporting quantitative outcomes for any type of intervention aiming to improve professional responses to disclosure of DVA with child involvement. We included interventions for physicians, nurses, social workers and teachers. Twenty‐one studies met the inclusion criteria: three randomised controlled trials (RCTs), 18 pre‐post intervention surveys. There were 18 training and three system‐level interventions. Training interventions generally had positive effects on participants' knowledge, attitudes towards DVA and clinical competence. The results from the RCTs were consistent with the before‐after surveys. Results from system‐level interventions aimed to change organisational practice and inter‐organisational collaboration demonstrates the benefit of coordinating system change in child welfare agencies with primary health care and other organisations. Implications for policy and research are discussed. © 2015 The Authors. Child Abuse Review published by John Wiley & Sons Ltd. ‘We searched 22 bibliographic databases and contacted topic experts’ Key Practitioner Messages We reviewed published evidence on interventions aimed at improving professionals' practice with domestic violence survivors and their children.Training programmes were found to improve participants' knowledge, attitudes and clinical competence up to a year after delivery.Key elements of successful training include interactive discussion, booster sessions and involving specialist domestic violence practitioners.Whole‐system approaches aiming to promote coordination and collaboration across agencies appear promising but require funding and high levels of commitment from partners. ‘Training programmes were found to improve participants' knowledge, attitudes and clinical competence up to a year after delivery’ PMID:28392674

Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions.

PubMed

Lamb, Sarah E; Becker, Clemens; Gillespie, Lesley D; Smith, Jessica L; Finnegan, Susanne; Potter, Rachel; Pfeiffer, Klaus

2011-05-17

Interventions for preventing falls in older people often involve several components, multidisciplinary teams, and implementation in a variety of settings. We have developed a classification system (taxonomy) to describe interventions used to prevent falls in older people, with the aim of improving the design and reporting of clinical trials of fall-prevention interventions, and synthesis of evidence from these trials. Thirty three international experts in falls prevention and health services research participated in a series of meetings to develop consensus. Robust techniques were used including literature reviews, expert presentations, and structured consensus workshops moderated by experienced facilitators. The taxonomy was refined using an international test panel of five health care practitioners. We assessed the chance corrected agreement of the final version by comparing taxonomy completion for 10 randomly selected published papers describing a variety of fall-prevention interventions. The taxonomy consists of four domains, summarized as the "Approach", "Base", "Components" and "Descriptors" of an intervention. Sub-domains include; where participants are identified; the theoretical approach of the intervention; clinical targeting criteria; details on assessments; descriptions of the nature and intensity of interventions. Chance corrected agreement of the final version of the taxonomy was good to excellent for all items. Further independent evaluation of the taxonomy is required. The taxonomy is a useful instrument for characterizing a broad range of interventions used in falls prevention. Investigators are encouraged to use the taxonomy to report their interventions.

Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions

PubMed Central

2011-01-01

Background Interventions for preventing falls in older people often involve several components, multidisciplinary teams, and implementation in a variety of settings. We have developed a classification system (taxonomy) to describe interventions used to prevent falls in older people, with the aim of improving the design and reporting of clinical trials of fall-prevention interventions, and synthesis of evidence from these trials. Methods Thirty three international experts in falls prevention and health services research participated in a series of meetings to develop consensus. Robust techniques were used including literature reviews, expert presentations, and structured consensus workshops moderated by experienced facilitators. The taxonomy was refined using an international test panel of five health care practitioners. We assessed the chance corrected agreement of the final version by comparing taxonomy completion for 10 randomly selected published papers describing a variety of fall-prevention interventions. Results The taxonomy consists of four domains, summarized as the "Approach", "Base", "Components" and "Descriptors" of an intervention. Sub-domains include; where participants are identified; the theoretical approach of the intervention; clinical targeting criteria; details on assessments; descriptions of the nature and intensity of interventions. Chance corrected agreement of the final version of the taxonomy was good to excellent for all items. Further independent evaluation of the taxonomy is required. Conclusions The taxonomy is a useful instrument for characterizing a broad range of interventions used in falls prevention. Investigators are encouraged to use the taxonomy to report their interventions. PMID:21586143

Audiovisual biofeedback breathing guidance for lung cancer patients receiving radiotherapy: a multi-institutional phase II randomised clinical trial.

PubMed

Pollock, Sean; O'Brien, Ricky; Makhija, Kuldeep; Hegi-Johnson, Fiona; Ludbrook, Jane; Rezo, Angela; Tse, Regina; Eade, Thomas; Yeghiaian-Alvandi, Roland; Gebski, Val; Keall, Paul J

2015-07-18

There is a clear link between irregular breathing and errors in medical imaging and radiation treatment. The audiovisual biofeedback system is an advanced form of respiratory guidance that has previously demonstrated to facilitate regular patient breathing. The clinical benefits of audiovisual biofeedback will be investigated in an upcoming multi-institutional, randomised, and stratified clinical trial recruiting a total of 75 lung cancer patients undergoing radiation therapy. To comprehensively perform a clinical evaluation of the audiovisual biofeedback system, a multi-institutional study will be performed. Our methodological framework will be based on the widely used Technology Acceptance Model, which gives qualitative scales for two specific variables, perceived usefulness and perceived ease of use, which are fundamental determinants for user acceptance. A total of 75 lung cancer patients will be recruited across seven radiation oncology departments across Australia. Patients will be randomised in a 2:1 ratio, with 2/3 of the patients being recruited into the intervention arm and 1/3 in the control arm. 2:1 randomisation is appropriate as within the interventional arm there is a screening procedure where only patients whose breathing is more regular with audiovisual biofeedback will continue to use this system for their imaging and treatment procedures. Patients within the intervention arm whose free breathing is more regular than audiovisual biofeedback in the screen procedure will remain in the intervention arm of the study but their imaging and treatment procedures will be performed without audiovisual biofeedback. Patients will also be stratified by treating institution and for treatment intent (palliative vs. radical) to ensure similar balance in the arms across the sites. Patients and hospital staff operating the audiovisual biofeedback system will complete questionnaires to assess their experience with audiovisual biofeedback. The objectives of this clinical trial is to assess the impact of audiovisual biofeedback on breathing motion, the patient experience and clinical confidence in the system, clinical workflow, treatment margins, and toxicity outcomes. This clinical trial marks an important milestone in breathing guidance studies as it will be the first randomised, controlled trial providing the most comprehensive evaluation of the clinical impact of breathing guidance on cancer radiation therapy to date. This study is powered to determine the impact of AV biofeedback on breathing regularity and medical image quality. Objectives such as determining the indications and contra-indications for the use of AV biofeedback, evaluation of patient experience, radiation toxicity occurrence and severity, and clinician confidence will shed light on the design of future phase III clinical trials. This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), its trial ID is ACTRN12613001177741 .

The Wild Wild West: A Framework to Integrate mHealth Software Applications and Wearables to Support Physical Activity Assessment, Counseling and Interventions for Cardiovascular Disease Risk Reduction

PubMed Central

Lobelo, Felipe; Kelli, Heval M.; Tejedor, Sheri Chernetsky; Pratt, Michael; McConnell, Michael V.; Martin, Seth S.; Welk, Gregory J.

2017-01-01

Physical activity (PA) interventions constitute a critical component of cardiovascular disease (CVD) risk reduction programs. Objective mobile health (mHealth) software applications (apps) and wearable activity monitors (WAMs) can advance both assessment and integration of PA counseling in clinical settings and support community-based PA interventions. The use of mHealth technology for CVD risk reduction is promising, but integration into routine clinical care and population health management has proven challenging. The increasing diversity of available technologies and the lack of a comprehensive guiding framework are key barriers for standardizing data collection and integration. This paper reviews the validity, utility and feasibility of implementing mHealth technology in clinical settings and proposes an organizational framework to support PA assessment, counseling and referrals to community resources for CVD risk reduction interventions. This integration framework can be adapted to different clinical population needs. It should also be refined as technologies and regulations advance under an evolving health care system landscape in the United States and globally. PMID:26923067

The Wild Wild West: A Framework to Integrate mHealth Software Applications and Wearables to Support Physical Activity Assessment, Counseling and Interventions for Cardiovascular Disease Risk Reduction.

PubMed

Lobelo, Felipe; Kelli, Heval M; Tejedor, Sheri Chernetsky; Pratt, Michael; McConnell, Michael V; Martin, Seth S; Welk, Gregory J

2016-01-01

Physical activity (PA) interventions constitute a critical component of cardiovascular disease (CVD) risk reduction programs. Objective mobile health (mHealth) software applications (apps) and wearable activity monitors (WAMs) can advance both assessment and integration of PA counseling in clinical settings and support community-based PA interventions. The use of mHealth technology for CVD risk reduction is promising, but integration into routine clinical care and population health management has proven challenging. The increasing diversity of available technologies and the lack of a comprehensive guiding framework are key barriers for standardizing data collection and integration. This paper reviews the validity, utility and feasibility of implementing mHealth technology in clinical settings and proposes an organizational framework to support PA assessment, counseling and referrals to community resources for CVD risk reduction interventions. This integration framework can be adapted to different clinical population needs. It should also be refined as technologies and regulations advance under an evolving health care system landscape in the United States and globally. Copyright © 2016 Elsevier Inc. All rights reserved.

Artificial Intelligence-Assisted Online Social Therapy for Youth Mental Health

PubMed Central

D'Alfonso, Simon; Santesteban-Echarri, Olga; Rice, Simon; Wadley, Greg; Lederman, Reeva; Miles, Christopher; Gleeson, John; Alvarez-Jimenez, Mario

2017-01-01

Introduction: Benefits from mental health early interventions may not be sustained over time, and longer-term intervention programs may be required to maintain early clinical gains. However, due to the high intensity of face-to-face early intervention treatments, this may not be feasible. Adjunctive internet-based interventions specifically designed for youth may provide a cost-effective and engaging alternative to prevent loss of intervention benefits. However, until now online interventions have relied on human moderators to deliver therapeutic content. More sophisticated models responsive to user data are critical to inform tailored online therapy. Thus, integration of user experience with a sophisticated and cutting-edge technology to deliver content is necessary to redefine online interventions in youth mental health. This paper discusses the development of the moderated online social therapy (MOST) web application, which provides an interactive social media-based platform for recovery in mental health. We provide an overview of the system's main features and discus our current work regarding the incorporation of advanced computational and artificial intelligence methods to enhance user engagement and improve the discovery and delivery of therapy content. Methods: Our case study is the ongoing Horyzons site (5-year randomized controlled trial for youth recovering from early psychosis), which is powered by MOST. We outline the motivation underlying the project and the web application's foundational features and interface. We discuss system innovations, including the incorporation of pertinent usage patterns as well as identifying certain limitations of the system. This leads to our current motivations and focus on using computational and artificial intelligence methods to enhance user engagement, and to further improve the system with novel mechanisms for the delivery of therapy content to users. In particular, we cover our usage of natural language analysis and chatbot technologies as strategies to tailor interventions and scale up the system. Conclusions: To date, the innovative MOST system has demonstrated viability in a series of clinical research trials. Given the data-driven opportunities afforded by the software system, observed usage patterns, and the aim to deploy it on a greater scale, an important next step in its evolution is the incorporation of advanced and automated content delivery mechanisms. PMID:28626431

Artificial Intelligence-Assisted Online Social Therapy for Youth Mental Health.

PubMed

D'Alfonso, Simon; Santesteban-Echarri, Olga; Rice, Simon; Wadley, Greg; Lederman, Reeva; Miles, Christopher; Gleeson, John; Alvarez-Jimenez, Mario

2017-01-01

Introduction: Benefits from mental health early interventions may not be sustained over time, and longer-term intervention programs may be required to maintain early clinical gains. However, due to the high intensity of face-to-face early intervention treatments, this may not be feasible. Adjunctive internet-based interventions specifically designed for youth may provide a cost-effective and engaging alternative to prevent loss of intervention benefits. However, until now online interventions have relied on human moderators to deliver therapeutic content. More sophisticated models responsive to user data are critical to inform tailored online therapy. Thus, integration of user experience with a sophisticated and cutting-edge technology to deliver content is necessary to redefine online interventions in youth mental health. This paper discusses the development of the moderated online social therapy (MOST) web application, which provides an interactive social media-based platform for recovery in mental health. We provide an overview of the system's main features and discus our current work regarding the incorporation of advanced computational and artificial intelligence methods to enhance user engagement and improve the discovery and delivery of therapy content. Methods: Our case study is the ongoing Horyzons site (5-year randomized controlled trial for youth recovering from early psychosis), which is powered by MOST. We outline the motivation underlying the project and the web application's foundational features and interface. We discuss system innovations, including the incorporation of pertinent usage patterns as well as identifying certain limitations of the system. This leads to our current motivations and focus on using computational and artificial intelligence methods to enhance user engagement, and to further improve the system with novel mechanisms for the delivery of therapy content to users. In particular, we cover our usage of natural language analysis and chatbot technologies as strategies to tailor interventions and scale up the system. Conclusions: To date, the innovative MOST system has demonstrated viability in a series of clinical research trials. Given the data-driven opportunities afforded by the software system, observed usage patterns, and the aim to deploy it on a greater scale, an important next step in its evolution is the incorporation of advanced and automated content delivery mechanisms.

The RESOLVE Trial for people with chronic low back pain: protocol for a randomised clinical trial.

PubMed

Bagg, Matthew K; Hübscher, Markus; Rabey, Martin; Wand, Benedict M; O'Hagan, Edel; Moseley, G Lorimer; Stanton, Tasha R; Maher, Chris G; Goodall, Stephen; Saing, Sopany; O'Connell, Neil E; Luomajoki, Hannu; McAuley, James H

2017-01-01

Low back pain is the leading worldwide cause of disability, and results in significant personal hardship. Most available treatments, when tested in high-quality randomised, controlled trials, achieve only modest improvements in pain, at best. Recently, treatments that target central nervous system function have been developed and tested in small studies. Combining treatments that target central nervous system function with traditional treatments directed towards functioning of the back is a promising approach that has yet to be tested in adequately powered, prospectively registered, clinical trials. The RESOLVE trial will be the first high-quality assessment of two treatment programs that combine central nervous system-directed and traditional interventions in order to improve chronic low back pain. To compare the effectiveness of two treatment programs that combine central nervous system-directed and traditional interventions at reducing pain intensity at 18 weeks post randomisation in a randomised clinical trial of people with chronic low back pain. Two-group, randomised, clinical trial with blinding of participants and assessors. Two hundred and seventy-five participants with chronic low back pain that has persisted longer than 3 months and no specific spinal pathology will be recruited from the community and primary care in Sydney, Australia. Both of the interventions contain treatments that target central nervous system function combined with treatments directed towards functioning of the back. Adherence to the intervention will be monitored using an individual treatment diary and adverse events recorded through passive capture. Participants are informed prior to providing informed consent that some of the treatments are not active. Blinding is maintained by not disclosing any further information. Complete disclosure of the contents of the intervention has been made with the UNSW HREC (HC15357) and an embargoed project registration has been made on the Open Science Framework to meet the Declaration of Helsinki requirement for transparent reporting of trial methods a priori. Participants randomised to Intervention A will receive a 12-session treatment program delivered as 60-minute sessions, scheduled approximately weekly, over a period of 12 to 18 weeks. All treatment sessions are one-on-one. The program includes a home treatment component of 30minutes, five times per week. The intervention comprises discussion of the participant's low back pain experience, graded sensory training, graded motor imagery training and graded, precision-focused and feedback-enriched, functional movement training. Treatment progression is determined by participant proficiency, with mandatory advancement at set time points with respect to a standard protocol. Participants randomised to Intervention B will receive a 12-session treatment program of the same duration and structure as Intervention A. The intervention comprises discussion of the participant's low back pain experience, transcranial direct current stimulation to the motor and pre-frontal cortices, cranial electrical stimulation, and low-intensity laser therapy and pulsed electromagnetic energy to the area of greatest pain. Treatment is delivered according to published recommendations and progressed with respect to a standard protocol. The primary outcome is pain intensity at 18 weeks post randomisation. Secondary outcomes will include disability, depression, pain catastrophising, kinesiophobia, beliefs about back pain, pain self-efficacy, quality of life, healthcare resource use, and treatment credibility. Assessment will occur at baseline and at 18, 26 and 52 weeks after randomisation. Treatment credibility will be assessed at baseline and 2 weeks after randomisation only. A statistician blinded to group status will analyse the data by intention-to-treat using linear mixed models with random intercepts. Linear contrasts will be constructed to compare the adjusted mean change (continuous variables) in outcome from baseline to each time point between intervention A and intervention B. This will provide effect estimates and 95% confidence intervals for any difference between the interventions. Preliminary data suggest that combining treatments that target central nervous system function with traditional interventions is a promising approach to chronic low back pain treatment. In the context of modest effects on pain intensity from most available treatments, this approach may lead to improved clinical outcomes for people with chronic low back pain. The trial will determine which, if either, of two treatment programs that combine central nervous system-directed and traditional interventions is more effective at reducing pain intensity in a chronic low back pain cohort. Central nervous system-directed interventions constitute a completely new treatment paradigm for chronic low back pain management. The results have the potential to be far reaching and change current physiotherapy management of chronic low back pain in Australia and internationally. Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.

The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes.

PubMed

Golden, Sherita Hill; Maruthur, Nisa; Mathioudakis, Nestoras; Spanakis, Elias; Rubin, Daniel; Zilbermint, Mihail; Hill-Briggs, Felicia

2017-07-01

The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes. Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.

Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke.

PubMed

Colomer, Carolina; Llorens, Roberto; Noé, Enrique; Alcañiz, Mariano

2016-05-11

Virtual and mixed reality systems have been suggested to promote motor recovery after stroke. Basing on the existing evidence on motor learning, we have developed a portable and low-cost mixed reality tabletop system that transforms a conventional table in a virtual environment for upper limb rehabilitation. The system allows intensive and customized training of a wide range of arm, hand, and finger movements and enables interaction with tangible objects, while providing audiovisual feedback of the participants' performance in gamified tasks. This study evaluates the clinical effectiveness and the acceptance of an experimental intervention with the system in chronic stroke survivors. Thirty individuals with stroke were included in a reversal (A-B-A) study. Phase A consisted of 30 sessions of conventional physical therapy. Phase B consisted of 30 training sessions with the experimental system. Both interventions involved flexion and extension of the elbow, wrist, and fingers, and grasping of different objects. Sessions were 45-min long and were administered three to five days a week. The body structures (Modified Ashworth Scale), functions (Motricity Index, Fugl-Meyer Assessment Scale), activities (Manual Function Test, Wolf Motor Function Test, Box and Blocks Test, Nine Hole Peg Test), and participation (Motor Activity Log) were assessed before and after each phase. Acceptance of the system was also assessed after phase B (System Usability Scale, Intrinsic Motivation Inventory). Significant improvement was detected after the intervention with the system in the activity, both in arm function measured by the Wolf Motor Function Test (p < 0.01) and finger dexterity measured by the Box and Blocks Test (p < 0.01) and the Nine Hole Peg Test (p < 0.01); and participation (p < 0.01), which was maintained to the end of the study. The experimental system was reported as highly usable, enjoyable, and motivating. Our results support the clinical effectiveness of mixed reality interventions that satisfy the motor learning principles for upper limb rehabilitation in chronic stroke survivors. This characteristic, together with the low cost of the system, its portability, and its acceptance could promote the integration of these systems in the clinical practice as an alternative to more expensive systems, such as robotic instruments.

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic.

PubMed

Skipper, Mads; Musaeus, Peter; Nøhr, Susanne Backman

2016-02-02

This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development. We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctors' workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention. The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind. The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role.

Barriers to participation in clinical trials: a physician survey.

PubMed

Mahmud, A; Zalay, O; Springer, A; Arts, K; Eisenhauer, E

2018-04-01

Clinical trials are vital for evidence-based cancer care. Oncologist engagement in clinical trials has an effect on patient recruitment, which in turn can affect trial success. Identifying barriers to clinical trial participation might enable interventions that could help to increase physician participation. To assess factors affecting physician engagement in oncology trials, a national survey was conducted using the online SurveyMonkey tool (SurveyMonkey, San Mateo, CA, U.S.A.; http://www.surveymonkey.com). Physicians associated with the Canadian Cancer Clinical Trials Network and the Canadian Cancer Trials Group were asked about their specialty, years of experience, barriers to participation, and motivating interventions, which included an open-ended question inviting survey takers to suggest interventions. The survey collected 207 anonymous responses. Respondents were predominantly medical oncologists (46.4%), followed by radiation oncologists (24.6%). Almost 70% of the respondents had more than 10 years of experience. Significant time constraints included extra paperwork (77%), patient education (54%), and extended follow-up or clinic visits (53%). Timing of events within trials was also a barrier to participation (55%). Most respondents favoured clinical work credits (72%), academic credits (67%), a clinical trial alert system (75%), a regular meeting to review trial protocols (65%), and a screening log to aid in patient accrual (67%) as motivational strategies. Suggested interventions included increased support staff, streamlined regulatory burden, and provision of greater funding for trials and easier access to ancillary services. The present study confirms that Canadian oncologists are willing to participate in clinical research, but face multiple barriers to trial participation. Those barriers could be mitigated by the implementation of several interventions identified in the study.

Psychological interventions for behavioral adjustments in diabetes care - a value-based approach to disease control.

PubMed

Chew, Boon-How; Fernandez, Aaron; Shariff-Ghazali, Sazlina

2018-01-01

Psychological aspects of a person, such as the personal value and belief systems, cognition and emotion, form the basis of human health behaviors, which, in turn, influence self-management, self-efficacy, quality of life, disease control and clinical outcomes in people with chronic diseases such as diabetes mellitus. However, psychological, psychosocial and behavioral interventions aimed at these groups of patients have yielded inconsistent effects in terms of clinical outcomes in clinical trials. This might have been due to differing conceptualization of health behavioral theories and models in the interventions. Assimilating different theories of human behavior, this narrative review attempts to demonstrate the potential modulatory effects of intrinsic values on cognitive and affective health-directed interventions. Interventions that utilize modification of cognition alone via education or that focuses on both cognitive and emotional levels are hardly adequate to initiate health-seeking behavior and much less to sustain them. People who are aware of their own personal values and purpose in life would be more motivated to practice good health-related behavior and persevere in them.

Effect of a pager notification system on Australasian Triage Scale category 2 patients in a paediatric emergency department.

PubMed

Cheng, Daryl R; McCartney, Laura E; West, Adam; Craig, Simon S

2016-08-01

Australasian EDs have introduced innovative processes to ensure safe and timely management of patients. Our ED introduced a dedicated pager system to provide rapid assessment of Australasian Triage Scale (ATS) category 2 patients in an attempt to expedite ED care. The present paper aims to evaluate the impact of this initiative on time to clinician, ED length of stay (LOS) and clinical outcomes in a tertiary paediatric ED. Retrospective structured chart review on patients presenting in a 2 month period before the intervention (August-September 2009) and the same time 1 year later. Patients were grouped into common ATS category 2 presentations and analysed in these subcategories. Clinical indicators of appropriate and timely performance were selected from best practice performance guidelines. 779 ATS category 2 patients were seen during the two periods: 370 pre-intervention and 409 post-intervention. The overall percentage of ATS category 2 patients seen within the target time increased by 22.3%, although there was no significant change in ED LOS. The median time for patients from triage to being seen by an ED clinician improved from 10 to 6 min (P < 0.01). However, we were unable to demonstrate an impact of the pager system on various clinical quality indicators. The rapid assessment pager system proved beneficial in reducing triage to clinician times for ATS category 2 patients but showed no improvement in overall ED LOS or disease-specific clinical quality indicators. Further research is needed to determine the influence of other components of ED functioning on clinical outcomes, as well as the overall clinical impact a pager system has on other measures of quality such as patient satisfaction and other subgroups of patients. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Pursuing cost-effectiveness in mental health service delivery for youth with complex needs.

PubMed

Grimes, Katherine E; Schulz, Margaret F; Cohen, Steven A; Mullin, Brian O; Lehar, Sophie E; Tien, Shelly

2011-06-01

Mental health advocates seek to expand children's services, noting widespread failure to meet the needs of public sector youth suffering from serious emotional disturbance (SED). However, state and national budgets face deepening cuts, with rising health care costs taking the blame. As the gap between needs and finances widens, identification of cost-effective treatments that will benefit children with SED and their families is of increasing importance. Community-based interventions for this population, such as the wraparound approach and systems-of-care, are being disseminated but literature is scant regarding effects on expense. The Mental Health Services Program for Youth (MHSPY) model is aligned philosophically with wraparound and systems-of-care but unique in blending public agency dollars to deliver integrated medical, mental health and social services. MHSPY's linked clinical and expense data is useful to study community-based treatment cost-effectiveness. To examine the cost-effectiveness of an intensively integrated, family and community-based clinical intervention for youth with mental health needs in comparison to "usual care.'' Study and reference populations were matched on age, gender, community, psychiatric diagnosis, morbidity and insurance type. Claims analyses included patterns of service utilization and medical expense for both groups. Using propensity score matching, results for study youth are compared with results for the population receiving "usual care.'' Clinical functioning was measured for the intervention group at baseline and 12 months. The intervention group used lower intensity services and had substantially lower claims expense (e.g. 32% lower for emergency room, 74% lower for inpatient psychiatry) than their matched counterparts in the "usual care'' group. Intervention youth were consistently maintained in least restrictive settings, with over 88% of days spent at home and showed improved clinical functioning on standard measures. The intensive MHSPY model of service delivery offers potential as a cost-effective intervention for complex youth. Its integrated approach, recognizing needs across multiple life domains, appears to enhance engagement and the effectiveness of mental health treatment, resulting in statistically significant clinical improvements. Functional measures are not collected in "usual care,'' limiting comparisons. However, claims expense for intervention youth was substantially lower than claims expense for Medicaid comparison youth, suggesting clinical needs for intervention youth post-enrollment were lower than for those receiving "usual care.'' The MHSPY model, which intentionally engages families in "clustered'' traditional and non-traditional services, represents a replicable strategy for enhancing the impact of clinical interventions, thereby reducing medical expense. Blending categorical state agency dollars and insurance funds creates flexibility to support community-based care, including individualized services for high-risk youth. Resulting expenses total no more, and are often less, than "treatment as usual'' but yield greater clinical benefits. Further research is needed regarding which intervention elements contribute the most towards improved clinical functioning, as well as which patients are most likely to benefit. A randomized trial of MHSPY vs. "usual care,'' including examination of the sustainability of effects post-disenrollment, would provide a chance to further test this innovative model.

Implementation and Evaluation of a Pilot Training to Improve Transgender Competency Among Medical Staff in an Urban Clinic.

PubMed

Lelutiu-Weinberger, Corina; Pollard-Thomas, Paula; Pagano, William; Levitt, Nathan; Lopez, Evelyn I; Golub, Sarit A; Radix, Asa E

2016-01-01

Purpose: Transgender individuals (TGI), who identify their gender as different from their sex assigned at birth, continue facing widespread discrimination and mistreatment within the healthcare system. Providers often lack expertise in adequate transgender (TG) care due to limited specialized training. In response to these inadequacies, and to increase evidence-based interventions effecting TG-affirmative healthcare, we implemented and evaluated a structural-level intervention in the form of a comprehensive Provider Training Program (PTP) in TG health within a New York City-based outpatient clinic serving primarily individuals of color and of low socioeconomic status. This pilot intervention aimed to increase medical staff knowledge of TG health and needs, and to support positive attitudes toward TGI. Methods: Three 2-h training sessions were delivered to 35 clinic staff across 4 months by two of the authors experienced in TG competency training; the training sessions included TG-related identity and barriers to healthcare issues, TG-specialized care, and creating TG-affirmative environments, medical forms, and billing procedures. We evaluated changes through pre-post intervention surveys by trainees. Results: Compared to pre-training scores, post-training scores indicated significant (1) decreases in negative attitudes toward TGI and increases in TG-related clinical skills, (2) increases in staff's awareness of transphobic practices, and (3) increases in self-reported readiness to serve TGI. The clinic increased its representation of general LGBT-related images in the waiting areas, and the staff provided highly positive training evaluations. Conclusion: This PTP in TG health shows promise in leading to changes in provider attitudes and competence, as well as clinic systems, especially with its incorporation in continuing education endeavors, which can, in turn, contribute to health disparities reductions among TG groups.

Using geographic information systems (GIS) to identify communities in need of health insurance outreach: An OCHIN practice-based research network (PBRN) report.

PubMed

Angier, Heather; Likumahuwa, Sonja; Finnegan, Sean; Vakarcs, Trisha; Nelson, Christine; Bazemore, Andrew; Carrozza, Mark; DeVoe, Jennifer E

2014-01-01

Our practice-based research network (PBRN) is conducting an outreach intervention to increase health insurance coverage for patients seen in the network. To assist with outreach site selection, we sought an understandable way to use electronic health record (EHR) data to locate uninsured patients. Health insurance information was displayed within a web-based mapping platform to demonstrate the feasibility of using geographic information systems (GIS) to visualize EHR data. This study used EHR data from 52 clinics in the OCHIN PBRN. We included cross-sectional coverage data for patients aged 0 to 64 years with at least 1 visit to a study clinic during 2011 (n = 228,284). Our PBRN was successful in using GIS to identify intervention sites. Through use of the maps, we found geographic variation in insurance rates of patients seeking care in OCHIN PBRN clinics. Insurance rates also varied by age: The percentage of adults without insurance ranged from 13.2% to 86.8%; rates of children lacking insurance ranged from 1.1% to 71.7%. GIS also showed some areas of households with median incomes that had low insurance rates. EHR data can be imported into a web-based GIS mapping tool to visualize patient information. Using EHR data, we were able to observe smaller areas than could be seen using only publicly available data. Using this information, we identified appropriate OCHIN PBRN clinics for dissemination of an EHR-based insurance outreach intervention. GIS could also be used by clinics to visualize other patient-level characteristics to target clinic outreach efforts or interventions. © Copyright 2014 by the American Board of Family Medicine.

Implementation and Evaluation of a Pilot Training to Improve Transgender Competency Among Medical Staff in an Urban Clinic

PubMed Central

Lelutiu-Weinberger, Corina; Pollard-Thomas, Paula; Pagano, William; Levitt, Nathan; Lopez, Evelyn I.; Golub, Sarit A.; Radix, Asa E.

2016-01-01

Abstract Purpose: Transgender individuals (TGI), who identify their gender as different from their sex assigned at birth, continue facing widespread discrimination and mistreatment within the healthcare system. Providers often lack expertise in adequate transgender (TG) care due to limited specialized training. In response to these inadequacies, and to increase evidence-based interventions effecting TG-affirmative healthcare, we implemented and evaluated a structural-level intervention in the form of a comprehensive Provider Training Program (PTP) in TG health within a New York City-based outpatient clinic serving primarily individuals of color and of low socioeconomic status. This pilot intervention aimed to increase medical staff knowledge of TG health and needs, and to support positive attitudes toward TGI. Methods: Three 2-h training sessions were delivered to 35 clinic staff across 4 months by two of the authors experienced in TG competency training; the training sessions included TG-related identity and barriers to healthcare issues, TG-specialized care, and creating TG-affirmative environments, medical forms, and billing procedures. We evaluated changes through pre-post intervention surveys by trainees. Results: Compared to pre-training scores, post-training scores indicated significant (1) decreases in negative attitudes toward TGI and increases in TG-related clinical skills, (2) increases in staff's awareness of transphobic practices, and (3) increases in self-reported readiness to serve TGI. The clinic increased its representation of general LGBT-related images in the waiting areas, and the staff provided highly positive training evaluations. Conclusion: This PTP in TG health shows promise in leading to changes in provider attitudes and competence, as well as clinic systems, especially with its incorporation in continuing education endeavors, which can, in turn, contribute to health disparities reductions among TG groups. PMID:29159297

Supporting clinical rules engine in the adjustment of medication (SCREAM): protocol of a multicentre, prospective, randomised study.

PubMed

Mestres Gonzalvo, Carlota; de Wit, Hugo A J M; van Oijen, Brigit P C; Hurkens, Kim P G M; Janknegt, Rob; Schols, Jos M G A; Mulder, Wubbo J; Verhey, Frans R; Winkens, Bjorn; van der Kuy, Paul-Hugo M

2017-01-26

In the nursing home population, it is estimated that 1 in every 3 patients is polymedicated and given their considerable frailty, these patients are especially prone to adverse drug reactions. Clinical pharmacist-led medication reviews are considered successful interventions to improve medication safety in the inpatient setting. Due to the limited available evidence concerning the benefits of medication reviews performed in the nursing home setting, we propose a study aiming to demonstrate a positive effect that a clinical decision support system, as a health care intervention, may have on the target population. The primary objective of this study is to reduce the number of patients with at least one event when using the clinical decision support system compared to the regular care. These events consist of hospital referrals, delirium, falls, and/or deaths. This study is a multicentre, prospective, randomised study with a cluster group design. The randomisation will be per main nursing home physician and stratified per ward (somatic and psychogeriatric). In the intervention group the clinical decision support system will be used to screen medication list, laboratory values and medical history in order to obtain potential clinical relevant remarks. The remarks will be sent to the main physician and feedback will be provided whether the advice was followed or not. In the control group regular care will be applied. We strongly believe that by using a clinical decision support system, medication reviews are performed in a standardised way which leads to comparable results between patients. In addition, using a clinical decision support system eliminates the time factor to perform medication reviews as the major problems related to medication, laboratory values, indications and/or established patient characteristics will be directly available. In this way, and in order to make the medication review process complete, consultation within healthcare professionals and/or the patient itself will be time effective and the medication surveillance could be performed around the clock. The Netherlands National Trial Register NTR5165 . Registered 2nd April 2015.

Impact of an Electronic Health Record-Integrated Personal Health Record on Patient Participation in Health Care: Development and Randomized Controlled Trial of MyHealthKeeper

PubMed Central

Ryu, Borim; Kim, Nari; Heo, Eunyoung; Yoo, Sooyoung; Lee, Keehyuck; Hwang, Hee; Kim, Jeong-Whun; Kim, Yoojung; Lee, Joongseek

2017-01-01

Background Personal health record (PHR)–based health care management systems can improve patient engagement and data-driven medical diagnosis in a clinical setting. Objective The purpose of this study was (1) to demonstrate the development of an electronic health record (EHR)–tethered PHR app named MyHealthKeeper, which can retrieve data from a wearable device and deliver these data to a hospital EHR system, and (2) to study the effectiveness of a PHR data-driven clinical intervention with clinical trial results. Methods To improve the conventional EHR-tethered PHR, we ascertained clinicians’ unmet needs regarding PHR functionality and the data frequently used in the field through a cocreation workshop. We incorporated the requirements into the system design and architecture of the MyHealthKeeper PHR module. We constructed the app and validated the effectiveness of the PHR module by conducting a 4-week clinical trial. We used a commercially available activity tracker (Misfit) to collect individual physical activity data, and developed the MyHealthKeeper mobile phone app to record participants’ patterns of daily food intake and activity logs. We randomly assigned 80 participants to either the PHR-based intervention group (n=51) or the control group (n=29). All of the study participants completed a paper-based survey, a laboratory test, a physical examination, and an opinion interview. During the 4-week study period, we collected health-related mobile data, and study participants visited the outpatient clinic twice and received PHR-based clinical diagnosis and recommendations. Results A total of 68 participants (44 in the intervention group and 24 in the control group) completed the study. The PHR intervention group showed significantly higher weight loss than the control group (mean 1.4 kg, 95% CI 0.9-1.9; P<.001) at the final week (week 4). In addition, triglyceride levels were significantly lower by the end of the study period (mean 2.59 mmol/L, 95% CI 17.6-75.8; P=.002). Conclusions We developed an innovative EHR-tethered PHR system that allowed clinicians and patients to share lifelog data. This study shows the effectiveness of a patient-managed and clinician-guided health tracker system and its potential to improve patient clinical profiles. Trial Registration ClinicalTrials.gov NCT03200119; https://clinicaltrials.gov/ct2/show/NCT03200119 (Archived by WebCite at http://www.webcitation.org/6v01HaCdd) PMID:29217503

A navigated mechatronic system with haptic features to assist in surgical interventions.

PubMed

Pieck, S; Gross, I; Knappe, P; Kuenzler, S; Kerschbaumer, F; Wahrburg, J

2003-01-01

In orthopaedic surgery, the development of new computer-based technologies such as navigation systems and robotics will facilitate more precise, reproducible results in surgical interventions. There are already commercial systems available for clinical use, though these still have some limitations and drawbacks. This paper presents an alternative approach to a universal modular surgical assistant system for supporting less or minimally invasive surgery. The position of a mechatronic arm, which is part of the system, is controlled by a navigation system so that small patient movements are automatically detected and compensated for in real time. Thus, the optimal tool position can be constantly maintained without the need for rigid bone or patient fixation. Furthermore, a force control mode of the mechatronic assistant system, based on a force-torque sensor, not only increases safety during surgical interventions but also facilitates hand-driven direct positioning of the arm. A prototype has been successfully tested in clinical applications at the Orthopadische Universitätsklinik Frankfurt. For the first time worldwide, implantation of the cup prosthesis in total hip replacement surgery has been carried out with the assistance of a mechatronic arm. According to measurements by the digitizing system, operating tool angle deviation remained below 0.5 degrees, relative to the preoperative planning. The presented approach to a new kind of surgical mechatronic assistance system supports the surgeon as needed by optimal positioning of the surgical instruments. Due to its modular design, it is applicable to a wide range of tasks in surgical interventions, e.g., endoscope guidance, bone preparation, etc.

Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice.

PubMed

Hansen, H; Metzl, J

2016-06-01

This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine.

Trial Watch—Immunostimulation with cytokines in cancer therapy

PubMed Central

Vacchelli, Erika; Aranda, Fernando; Bloy, Norma; Buqué, Aitziber; Cremer, Isabelle; Eggermont, Alexander; Fridman, Wolf Hervé; Fucikova, Jitka; Galon, Jérôme; Spisek, Radek; Zitvogel, Laurence; Kroemer, Guido; Galluzzi, Lorenzo

2016-01-01

ABSTRACT During the past decade, great efforts have been dedicated to the development of clinically relevant interventions that would trigger potent (and hence potentially curative) anticancer immune responses. Indeed, developing neoplasms normally establish local and systemic immunosuppressive networks that inhibit tumor-targeting immune effector cells, be them natural or elicited by (immuno)therapy. One possible approach to boost anticancer immunity consists in the (generally systemic) administration of recombinant immunostimulatory cytokines. In a limited number of oncological indications, immunostimulatory cytokines mediate clinical activity as standalone immunotherapeutic interventions. Most often, however, immunostimulatory cytokines are employed as immunological adjuvants, i.e., to unleash the immunogenic potential of other immunotherapeutic agents, like tumor-targeting vaccines and checkpoint blockers. Here, we discuss recent preclinical and clinical advances in the use of some cytokines as immunostimulatory agents in oncological indications. PMID:27057468

Implementation of a Family Planning Clinic-Based Partner Violence and Reproductive Coercion Intervention: Provider and Patient Perspectives.

PubMed

Miller, Elizabeth; McCauley, Heather L; Decker, Michele R; Levenson, Rebecca; Zelazny, Sarah; Jones, Kelley A; Anderson, Heather; Silverman, Jay G

2017-06-01

Despite multiple calls for clinic-based services to identify and support women victimized by partner violence, screening remains uncommon in family planning clinics. Furthermore, traditional screening, based on disclosure of violence, may miss women who fear reporting their experiences. Strategies that are sensitive to the signs, symptoms and impact of trauma require exploration. In 2011, as part of a cluster randomized controlled trial, staff at 11 Pennsylvania family planning clinics were trained to offer a trauma-informed intervention addressing intimate partner violence and reproductive coercion to all women seeking care, regardless of exposure to violence. The intervention sought to educate women about available resources and harm reduction strategies. In 2013, at the conclusion of the trial, 18 providers, five administrators and 49 patients completed semistructured interviews exploring acceptability of the intervention and barriers to implementation. Consensus and open coding strategies were used to analyze the data. Providers reported that the intervention increased their confidence in discussing intimate partner violence and reproductive coercion. They noted that asking patients to share the educational information with other women facilitated the conversation. Barriers to implementation included lack of time and not having routine reminders to offer the intervention. Patients described how receiving the intervention gave them important information, made them feel supported and less isolated, and empowered them to help others. A universal intervention may be acceptable to providers and patients. However, successful implementation in family planning settings may require attention to system-level factors that providers view as barriers. Copyright © 2017 by the Guttmacher Institute.

Evaluation of a Shared Decision-Making Intervention on the Utilization of Evidence-Based Psychotherapy in a VA Outpatient PTSD Clinic.

PubMed

Hessinger, Jonathan D; London, Melissa J; Baer, Sheila M

2017-03-13

The Veterans Health Administration (VHA) has continued to emphasize the availability, access, and utilization of high quality mental health care particularly in the treatment of posttraumatic stress disorder (PTSD). While dissemination and availability of evidence-based psychotherapies (EBPs) have only increased, treatment engagement and utilization have continued to be oft-noted challenges. Administrators, researchers, and individual clinicians have continued to develop and explore novel systemic and individualized interventions to address these issues. Pilot studies utilizing shared decision-making models to aid in veteran treatment selection have demonstrated the impact this approach may have on selection of and engagement in EBPs for PTSD. Based on these promising studies, a Department of Veterans Affairs (VA) outpatient PTSD clinic began to implement a shared-decision making intervention as part of a clinic redesign. In seeking to evaluate the impact of this intervention, archival clinical data from 1,056 veterans were reviewed by the authors for rates of treatment selection, EBP initiation, session attendance, and EBP completion. Time elapsed from consult until EBP initiation was also computed by the authors. These variables were then compared on the basis of whether the veteran received the shared-decision making intervention. Veterans who received the intervention were more likely to select and thus initiate an EBP for PTSD sooner than veterans who did not receive this intervention. Veterans, whether receiving the intervention or not, did not differ in therapy session attendance and completion. Implications of these findings and directions for future study are further discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Promotion of tobacco use cessation for lesbian, gay, bisexual, and transgender people: a systematic review.

PubMed

Lee, Joseph G L; Matthews, Alicia K; McCullen, Cramer A; Melvin, Cathy L

2014-12-01

Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use, given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of grey and peer-reviewed literature describing clinical, community, and policy interventions, as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people. Eight databases for articles from 1987 to April 23, 2014, were searched. In February-November 2013, authors and researchers were contacted to identify grey literature. The search identified 57 records, of which 51 were included and 22 were from the grey literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October 2013-May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities, although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting the messaging used in media campaigns. LGBT-serving organizations should implement existing evidence-based tobacco-dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions. Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Community health workers' experiences of mobile device-enabled clinical decision support systems for maternal, newborn and child health in developing countries: a qualitative systematic review protocol.

PubMed

Dzabeng, Francis; Enuameh, Yeetey; Adjei, George; Manu, Grace; Asante, Kwaku Poku; Owusu-Agyei, Seth

2016-09-01

The objective of this review is to synthesize evidence on the experiences of community health workers (CHWs) of mobile device-enabled clinical decision support systems (CDSSs) interventions designed to support maternal newborn and child health (MNCH) in low-and middle-income countries.Specific objectives.

Moving electronic medical records upstream: incorporating social determinants of health.

PubMed

Gottlieb, Laura M; Tirozzi, Karen J; Manchanda, Rishi; Burns, Abby R; Sandel, Megan T

2015-02-01

Knowledge of the biological pathways and mechanisms connecting social factors with health has increased exponentially over the past 25 years, yet in most clinical settings, screening and intervention around social determinants of health are not part of standard clinical care. Electronic medical records provide new opportunities for assessing and managing social needs in clinical settings, particularly those serving vulnerable populations. To illustrate the feasibility of capturing information and promoting interventions related to social determinants of health in electronic medical records. Three case studies were examined in which electronic medical records have been used to collect data and address social determinants of health in clinical settings. From these case studies, we identified multiple functions that electronic medical records can perform to facilitate the integration of social determinants of health into clinical systems, including screening, triaging, referring, tracking, and data sharing. If barriers related to incentives, training, and privacy can be overcome, electronic medical record systems can improve the integration of social determinants of health into healthcare delivery systems. More evidence is needed to evaluate the impact of such integration on health care outcomes before widespread adoption can be recommended. Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

REACH VA: Moving from Translation to System Implementation.

PubMed

Nichols, Linda O; Martindale-Adams, Jennifer; Burns, Robert; Zuber, Jeffrey; Graney, Marshall J

2016-02-01

Resources for Enhancing All Caregivers Health in the Department of Veterans Affairs (REACH VA) has been implemented in the VA system as a national program for caregivers. We describe the trajectory of REACH VA from national randomized clinical trial through translation to national implementation. The implementation is examined through the six stages of the Fixsen and Blasé implementation process model: exploration and adoption, program installation, initial implementation, full operation, innovation, and sustainability. Different drivers that move the implementation process forward are important at each stage, including staff selection, staff training, consultation and coaching, staff evaluation, administrative support, program evaluation/fidelity, and systems interventions. Caregivers in the REACH VA 4 session intervention currently implemented in the VA had similar outcomes to longer REACH interventions, including Resources for Enhancing Alzheimer's Caregivers Health (REACH II). Caregivers experienced significant decreases in burden, depression, anxiety, number of troubling patient behaviors reported, caregiving frustrations, stress symptoms (feeling overwhelmed, feeling like crying, being frustrated as a result of caregiving, being lonely), and general stress. Effect sizes (Cohen's d) for these significant variables were between small and medium ranging from .24 to .46. The implementation of REACH VA provides a road map for implementation of other behavioral interventions in health care delivery settings. Lessons learned include the importance of implementing a proven, needed intervention, support from both leadership and clinical staff, willingness to respond to staff and organization needs and modify the intervention while preserving its integrity, and fitting the intervention into ongoing routines and practices. Published by Oxford University Press on behalf of the Gerontological Society of America 2014.

Interventional MRI-guided catheter placement and real time drug delivery to the central nervous system.

PubMed

Han, Seunggu J; Bankiewicz, Krystof; Butowski, Nicholas A; Larson, Paul S; Aghi, Manish K

2016-06-01

Local delivery of therapeutic agents into the brain has many advantages; however, the inability to predict, visualize and confirm the infusion into the intended target has been a major hurdle in its clinical development. Here, we describe the current workflow and application of the interventional MRI (iMRI) system for catheter placement and real time visualization of infusion. We have applied real time convection-enhanced delivery (CED) of therapeutic agents with iMRI across a number of different clinical trials settings in neuro-oncology and movement disorders. Ongoing developments and accumulating experience with the technique and technology of drug formulations, CED platforms, and iMRI systems will continue to make local therapeutic delivery into the brain more accurate, efficient, effective and safer.

Opening caregiver minds: National Alliance for the Mentally Ill's (NAMI) provider education program.

PubMed

Mohr, W K; Lafuze, J E; Mohr, B D

2000-10-01

The belief that poor parenting and dysfunctional families give rise to mental illness has been perpetuated by psychodynamic and family systems theories that lack supporting scientific evidence, and interventions based on these theories have failed to produce clinical improvements. Nevertheless the National Alliance for the Mentally III (NAMI) found that many clinical training programs continue to teach these outdated theories and interventions and that the mental health system is often destructive to family systems. This article describes a new 10-week program that is designed to educate service providers that will include families in the care of their chronically ill loved one. The program is based on a competence and adaptation rather than a pathology foundation and it shifts the discourse from causes to effects of illness.

Features and Effects of Information Technology-Based Interventions to Improve Self-Management in Chronic Kidney Disease Patients: a Systematic Review of the Literature.

PubMed

Jeddi, Fateme Rangraz; Nabovati, Ehsan; Amirazodi, Shahrzad

2017-09-18

Slowing down the progression of chronic kidney disease (CKD) and its adverse health outcomes requires the patient's self-management and attention to treatment recommendations. Information technology (IT)-based interventions are increasingly being used to support self-management in patients with chronic diseases such as CKD. We conducted a systematic review of randomized controlled trials (RCTs) to assess the features and effects of IT-based interventions on self-management outcomes of CKD patients. A comprehensive search was conducted in Medline, Scopus, and the Cochrane Library to identify relevant papers that were published until May 2016. RCT Studies that assessed at least one automated IT tool in patients with CKD stages 1 to 5, and reported at least one self-management outcome were included. Studies were appraised for quality using the Cochrane Risk of Bias assessment tool. Out of 12,215 papers retrieved, eight study met the inclusion criteria. Interventions were delivered via smartphones/personal digital assistants (PDAs) (three studies), wearable devices (three studies), computerized systems (one study), and multiple component (one study). The studies assessed 15 outcomes, including eight clinical outcomes and seven process of care outcomes. In 12 (80%) of the 15 outcomes, the studies had revealed the effects of the interventions as statistically significant positive. These positive effects were observed in 75% of the clinical outcomes and 86% of the process of care outcomes. The evidence indicates the potential of IT-based interventions (i.e. smartphones/PDAs, wearable devices, and computerized systems) in self-management outcomes (clinical and process of care outcomes) of CKD patients.

Techniques for Interventional MRI Guidance in Closed-Bore Systems.

PubMed

Busse, Harald; Kahn, Thomas; Moche, Michael

2018-02-01

Efficient image guidance is the basis for minimally invasive interventions. In comparison with X-ray, computed tomography (CT), or ultrasound imaging, magnetic resonance imaging (MRI) provides the best soft tissue contrast without ionizing radiation and is therefore predestined for procedural control. But MRI is also characterized by spatial constraints, electromagnetic interactions, long imaging times, and resulting workflow issues. Although many technical requirements have been met over the years-most notably magnetic resonance (MR) compatibility of tools, interventional pulse sequences, and powerful processing hardware and software-there is still a large variety of stand-alone devices and systems for specific procedures only.Stereotactic guidance with the table outside the magnet is common and relies on proper registration of the guiding grids or manipulators to the MR images. Instrument tracking, often by optical sensing, can be added to provide the physicians with proper eye-hand coordination during their navigated approach. Only in very short wide-bore systems, needles can be advanced at the extended arm under near real-time imaging. In standard magnets, control and workflow may be improved by remote operation using robotic or manual driving elements.This work highlights a number of devices and techniques for different interventional settings with a focus on percutaneous, interstitial procedures in different organ regions. The goal is to identify technical and procedural elements that might be relevant for interventional guidance in a broader context, independent of the clinical application given here. Key challenges remain the seamless integration into the interventional workflow, safe clinical translation, and proper cost effectiveness.

Effectiveness of the EMPOWER-PAR Intervention in Improving Clinical Outcomes of Type 2 Diabetes Mellitus in Primary Care: A Pragmatic Cluster Randomised Controlled Trial.

PubMed

Ramli, Anis Safura; Selvarajah, Sharmini; Daud, Maryam Hannah; Haniff, Jamaiyah; Abdul-Razak, Suraya; Tg-Abu-Bakar-Sidik, Tg Mohd Ikhwan; Bujang, Mohamad Adam; Chew, Boon How; Rahman, Thuhairah; Tong, Seng Fah; Shafie, Asrul Akmal; Lee, Verna K M; Ng, Kien Keat; Ariffin, Farnaza; Abdul-Hamid, Hasidah; Mazapuspavina, Md Yasin; Mat-Nasir, Nafiza; Chan, Chun W; Yong-Rafidah, Abdul Rahman; Ismail, Mastura; Lakshmanan, Sharmila; Low, Wilson H H

2016-11-14

The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting. This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c < 6.5%. Secondary outcomes were the change in proportion of patients achieving targets for blood pressure, lipid profile, body mass index and waist circumference. Intention to treat analysis was performed for all outcome measures. A generalised estimating equation method was used to account for baseline differences and clustering effect. A total of 888 type 2 diabetes mellitus patients were recruited at baseline (intervention: 471 vs. 417). At 1-year, 96.6 and 97.8% of patients in the intervention and control groups completed the study, respectively. The baseline demographic and clinical characteristics of both groups were comparable. The change in the proportion of patients achieving HbA1c target was significantly higher in the intervention compared to the control group (intervention: 3.0% vs. -4.1%, P < 0.002). Patients who received the EMPOWER-PAR intervention were twice more likely to achieve HbA1c target compared to those in the control group (adjusted OR 2.16, 95% CI 1.34-3.50, P < 0.002). However, there was no significant improvement found in the secondary outcomes. This study demonstrates that the EMPOWER-PAR intervention was effective in improving the primary outcome for type 2 diabetes in the Malaysian public primary care setting. Registered with: ClinicalTrials.gov.: NCT01545401 . Date of registration: 1st March 2012.

Costs associated with implementation of computer-assisted clinical decision support system for antenatal and delivery care: case study of Kassena-Nankana district of northern Ghana.

PubMed

Dalaba, Maxwell Ayindenaba; Akweongo, Patricia; Williams, John; Saronga, Happiness Pius; Tonchev, Pencho; Sauerborn, Rainer; Mensah, Nathan; Blank, Antje; Kaltschmidt, Jens; Loukanova, Svetla

2014-01-01

This study analyzed cost of implementing computer-assisted Clinical Decision Support System (CDSS) in selected health care centres in Ghana. A descriptive cross sectional study was conducted in the Kassena-Nankana district (KND). CDSS was deployed in selected health centres in KND as an intervention to manage patients attending antenatal clinics and the labour ward. The CDSS users were mainly nurses who were trained. Activities and associated costs involved in the implementation of CDSS (pre-intervention and intervention) were collected for the period between 2009-2013 from the provider perspective. The ingredients approach was used for the cost analysis. Costs were grouped into personnel, trainings, overheads (recurrent costs) and equipment costs (capital cost). We calculated cost without annualizing capital cost to represent financial cost and cost with annualizing capital costs to represent economic cost. Twenty-two trained CDSS users (at least 2 users per health centre) participated in the study. Between April 2012 and March 2013, users managed 5,595 antenatal clients and 872 labour clients using the CDSS. We observed a decrease in the proportion of complications during delivery (pre-intervention 10.74% versus post-intervention 9.64%) and a reduction in the number of maternal deaths (pre-intervention 4 deaths versus post-intervention 1 death). The overall financial cost of CDSS implementation was US$23,316, approximately US$1,060 per CDSS user trained. Of the total cost of implementation, 48% (US$11,272) was pre-intervention cost and intervention cost was 52% (US$12,044). Equipment costs accounted for the largest proportion of financial cost: 34% (US$7,917). When economic cost was considered, total cost of implementation was US$17,128-lower than the financial cost by 26.5%. The study provides useful information in the implementation of CDSS at health facilities to enhance health workers' adherence to practice guidelines and taking accurate decisions to improve maternal health care.

Changing physician behavior: what works?

PubMed

Mostofian, Fargoi; Ruban, Cynthiya; Simunovic, Nicole; Bhandari, Mohit

2015-01-01

There are various interventions for guideline implementation in clinical practice, but the effects of these interventions are generally unclear. We conducted a systematic review to identify effective methods of implementing clinical research findings and clinical guidelines to change physician practice patterns, in surgical and general practice. Systematic review of reviews. We searched electronic databases (MEDLINE, EMBASE, and PubMed) for systematic reviews published in English that evaluated the effectiveness of different implementation methods. Two reviewers independently assessed eligibility for inclusion and methodological quality, and extracted relevant data. Fourteen reviews covering a wide range of interventions were identified. The intervention methods used include: audit and feedback, computerized decision support systems, continuing medical education, financial incentives, local opinion leaders, marketing, passive dissemination of information, patient-mediated interventions, reminders, and multifaceted interventions. Active approaches, such as academic detailing, led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active educational methods and multifaceted interventions. Active forms of continuing medical education and multifaceted interventions were found to be the most effective methods for implementing guidelines into general practice. Additionally, active approaches to changing physician performance were shown to improve practice to a greater extent than traditional passive methods. Further primary research is necessary to evaluate the effectiveness of these methods in a surgical setting.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

PubMed Central

Liu, Nancy H.; Daumit, Gail L.; Dua, Tarun; Aquila, Ralph; Charlson, Fiona; Cuijpers, Pim; Druss, Benjamin; Dudek, Kenn; Freeman, Melvyn; Fujii, Chiyo; Gaebel, Wolfgang; Hegerl, Ulrich; Levav, Itzhak; Munk Laursen, Thomas; Ma, Hong; Maj, Mario; Elena Medina‐Mora, Maria; Nordentoft, Merete; Prabhakaran, Dorairaj; Pratt, Karen; Prince, Martin; Rangaswamy, Thara; Shiers, David; Susser, Ezra; Thornicroft, Graham; Wahlbeck, Kristian; Fekadu Wassie, Abe; Whiteford, Harvey; Saxena, Shekhar

2017-01-01

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio‐environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual‐focused, health system‐focused, and community level and policy‐focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas. PMID:28127922

Clinical pathway across tertiary and community care after an interventional cardiology procedure.

PubMed

Doran, K; Sampson, B; Staus, R; Ahern, C; Schiro, D

1997-01-01

Many patients who receive medical interventional cardiology procedures at a tertiary hospital live outside the metropolitan area and may experience fragmentation in care, less emotional support by family members, inaccurate and delayed communication, and lack of educational follow-up on discharge from the hospital. A clinical pathway titled "Heart Health Care Patterns" was developed to link acute phase, recovery phase, rehabilitation phase, and enhancement/maintenance phase. The 12-month clinical pathway combines Gordon's Functional Health Patterns and the Omaha System developed by the Omaha Visiting Nurse Association. The rating scale for outcomes assesses the patient at different phases to provide objective data and information throughout the year.

Improving performance with clinical decision support.

PubMed

Brailer, D J; Goldfarb, S; Horgan, M; Katz, F; Paulus, R A; Zakrewski, K

1996-07-01

CADU/CIS (Clinical and Administrative Decision-support Utility and Clinical Information System) is a clinical decision-support workstation that allows large volumes of clinical information systems data to be analyzed in a timely and user-friendly fashion. CARE PROCESS MEASUREMENT: For any given disease, subgroups of patients are identified, and automated, customized "clinical pathways" are generated. For each subgroup, the best practice norms for use of test and therapies are identified. Practice style variations are then compared to outcomes to focus inquiry on decisions that significantly affect outcomes. INTESTINAL OBSTRUCTION: Graduate Health Systems, a multisite integrated provider in the Philadelphia area, has used CADU/CIS to improve quality problems, reduce treatment-intensity variations, and improve clinical participation in care process evaluation and decision making. A task force selected intestinal obstruction without hernia as its first study because of the related high-volume and high-morbidity complications. Use of a ten-step method for clinical performance improvement showed that the intravenous administration of unnecessary fluids to 104 patients with intestinal obstruction induced congestive heart failure (CHF) in 5 patients. Task force members and other practicing physicians are now developing guidelines and other interventions aimed at fluid use. Indeed, the task force used CADU/CIS to identify an additional 250 patients in one year whose conditions were complicated by CHF. A clinical decision support tool can be instrumental in detecting problems with important clinical and economic implications, identifying their important underlying causes, tracking the associated tests and therapies, and monitoring interventions.

Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: a qualitative study to guide clinic-based interventions.

PubMed

Cattamanchi, Adithya; Miller, Cecily R; Tapley, Asa; Haguma, Priscilla; Ochom, Emmanuel; Ackerman, Sara; Davis, J Lucian; Katamba, Achilles; Handley, Margaret A

2015-01-22

Studies of the quality of tuberculosis (TB) diagnostic evaluation of patients in high burden countries have generally shown poor adherence to international or national guidelines. Health worker perspectives on barriers to improving TB diagnostic evaluation are critical for developing clinic-level interventions to improve guideline implementation. We conducted structured, in-depth interviews with staff at six district-level health centers in Uganda to elicit their perceptions regarding barriers to TB evaluation. Interviews were transcribed, coded with a standardized framework, and analyzed to identify emergent themes. We used thematic analysis to develop a logic model depicting health system and contextual barriers to recommended TB evaluation practices. To identify possible clinic-level interventions to improve TB evaluation, we categorized findings into predisposing, enabling, and reinforcing factors as described by the PRECEDE model, focusing on potentially modifiable behaviors at the clinic-level. We interviewed 22 health center staff between February 2010 and November 2011. Participants identified key health system barriers hindering TB evaluation, including: stock-outs of drugs/supplies, inadequate space and infrastructure, lack of training, high workload, low staff motivation, and poor coordination of health center services. Contextual barrier challenges to TB evaluation were also reported, including the time and costs borne by patients to seek and complete TB evaluation, poor health literacy, and stigma against patients with TB. These contextual barriers interacted with health system barriers to contribute to sub-standard TB evaluation. Examples of intervention strategies that could address these barriers and are related to PRECEDE model components include: assigned mentors/peer coaching for new staff (targets predisposing factor of low motivation and need for support to conduct job duties); facilitated workshops to implement same day microscopy (targets enabling factor of patient barriers to completing TB evaluation), and recognition/incentives for good TB screening practices (targets low motivation and self-efficacy). Our findings suggest that health system and contextual barriers work together to impede TB diagnosis at health centers and, if not addressed, could hinder TB case detection efforts. Qualitative research that improves understanding of the barriers facing TB providers is critical to developing targeted interventions to improve TB care.

Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials

PubMed Central

2012-01-01

Background Osteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care. Methods / Design One study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the Short Physical Performance Test Protocol (objective physical function) and the Patient Health Questionnaire-8 (depressive symptoms). Cost effectiveness of the interventions will also be assessed. Discussion Results of these two studies will further our understanding of the most effective strategies for improving hip and knee OA outcomes in primary care settings. Trial registration NCT01130740 (VA); NCT 01435109 (NIH) PMID:22530979

Effects of a computerized feedback intervention on safety performance by junior doctors: results from a randomized mixed method study

PubMed Central

2013-01-01

Background The behaviour of doctors and their responses to warnings can inform the effective design of Clinical Decision Support Systems. We used data from a University hospital electronic prescribing and laboratory reporting system with hierarchical warnings and alerts to explore junior doctors’ behaviour. The objective of this trial was to establish whether a Junior Doctor Dashboard providing feedback on prescription warning information and laboratory alerting acceptance rates was effective in changing junior doctors’ behaviour. Methods A mixed methods approach was employed which included a parallel group randomised controlled trial, and individual and focus group interviews. Junior doctors below the specialty trainee level 3 grade were recruited and randomised to two groups. Every doctor (N = 42) in the intervention group was e-mailed a link to a personal dashboard every week for 4 months. Nineteen participated in interviews. The 44 control doctors did not receive any automated feedback. The outcome measures were the difference in responses to prescribing warnings (of two severities) and laboratory alerting (of two severities) between the months before and the months during the intervention, analysed as the difference in performance between the intervention and the control groups. Results No significant differences were observed in the rates of generating prescription warnings, or in the acceptance of laboratory alarms. However, responses to laboratory alerts differed between the pre-intervention and intervention periods. For the doctors of Foundation Year 1 grade, this improvement was significantly (p = 0.002) greater in the group with access to the dashboard (53.6% ignored pre-intervention compared to 29.2% post intervention) than in the control group (47.9% ignored pre-intervention compared to 47.0% post intervention). Qualitative interview data indicated that while junior doctors were positive about the electronic prescribing functions, they were discriminating in the way they responded to other alerts and warnings given that from their perspective these were not always immediately clinically relevant or within the scope of their responsibility. Conclusions We have only been able to provide weak evidence that a clinical dashboard providing individualized feedback data has the potential to improve safety behaviour and only in one of several domains. The construction of metrics used in clinical dashboards must take account of actual work processes. Trial registration ISRCTN: ISRCTN72253051 PMID:23734871

Clinical decision support provided within physician order entry systems: a systematic review of features effective for changing clinician behavior.

PubMed

Kawamoto, Kensaku; Lobach, David F

2003-01-01

Computerized physician order entry (CPOE) systems represent an important tool for providing clinical decision support. In undertaking this systematic review, our objective was to identify the features of CPOE-based clinical decision support systems (CDSSs) most effective at modifying clinician behavior. For this review, two independent reviewers systematically identified randomized controlled trials that evaluated the effectiveness of CPOE-based CDSSs in changing clinician behavior. Furthermore, each included study was assessed for the presence of 14 CDSS features. We screened 10,023 citations and included 11 studies. Of the 10 studies comparing a CPOE-based CDSS intervention against a non-CDSS control group, 7 reported a significant desired change in professional practice. Moreover, meta-regression analysis revealed that automatic provision of the decision support was strongly associated with improved professional practice (adjusted odds ratio, 23.72; 95% confidence interval, 1.75-infiniti). Thus, we conclude that automatic provision of decision support is a critical feature of successful CPOE-based CDSS interventions.

Increasing Human Papillomavirus Vaccine Initiation among Publically-Insured Florida Adolescents

PubMed Central

Staras, Stephanie A. S.; Vadaparampil, Susan T.; Livingston, Melvin D.; Thompson, Lindsay A.; Sanders, Ashley H.; Shenkman, Elizabeth A.

2014-01-01

Purpose We evaluated the feasibility of a multi-level intervention to increase HPV vaccine initiation among adolescents. Methods We used a four-arm factorial quasi-experimental trial to assess feasibility and short-term, preliminary effectiveness of a health system-level, gender-specific postcard campaign and an in-clinic health information technology (HIT) system. Between August to November 2013, we tested the intervention among 11–17 year olds without prior HPV vaccine claims in Florida Medicaid or Children’s Health Insurance Program encounters (2773 girls and 3350 boys) who attended or were assigned to primary care clinics in North Central Florida. Results At least one postcard was deliverable to 95% of parents. Most parents (91% boys’ and 80% girls’) who participated in the process evaluation survey (n=162) reported seeking additional information about the vaccine after receiving the postcard. Only 8% (57 of the 1062) of adolescents assigned to a HIT provider with an office visit during the study used the HIT system. When compared with arms not containing that component, HPV vaccine initiation increased with the postcard campaign [girls Odds Ratio (OR) = 1.6, 95% Confidence Interval (CI) = 1.1–2.3 and boys = not significant], the HIT system (girls OR = 1.5, 95% CI =1.0–2.3 and boys OR = 1.4, 95% CI=1.0–2.0), and the combined HIT and postcard intervention (girls OR = 2.4, 95% CI =1.4–4.3 and boys OR = 1.6, 95% CI=1.0–2.5). Conclusions A system-level postcard campaign was feasible. Despite low recruitment to the inclinic HIT system, the intervention demonstrated short-term, preliminary effectiveness similar to prior HPV vaccine interventions. PMID:25863554

When Gender Identity Doesn't Equal Sex Recorded at Birth: The Role of the Laboratory in Providing Effective Healthcare to the Transgender Community.

PubMed

Goldstein, Zil; Corneil, Trevor A; Greene, Dina N

2017-08-01

Transgender is an umbrella term used to describe individuals who identify with a gender incongruent to or variant from their sex recorded at birth. Affirming gender identity through a variety of social, medical, and surgical interventions is critical to the mental health of transgender individuals. In recent years, awareness surrounding transgender identities has increased, which has highlighted the health disparities that parallel this demographic. These disparities are reflected in the experience of transgender patients and their providers when seeking clinical laboratory services. Little is known about the effect of gender-affirming hormone therapy and surgery on optimal laboratory test interpretation. Efforts to diminish health disparities encountered by transgender individuals and their providers can be accomplished by increasing social and clinical awareness regarding sex/gender incongruence and gaining insight into the physiological manifestations and laboratory interpretations of gender-affirming strategies. This review summarizes knowledge required to understand transgender healthcare including current clinical interventions for gender dysphoria. Particular attention is paid to the subsequent impact of these interventions on laboratory test utilization and interpretation. Common nomenclature and system barriers are also discussed. Understanding gender incongruence, the clinical changes associated with gender transition, and systemic barriers that maintain a gender/sex binary are key to providing adequate healthcare to transgender community. Transgender appropriate reference interval studies are virtually absent within the medical literature and should be explored. The laboratory has an important role in improving the physiological understanding, electronic medical system recognition, and overall social awareness of the transgender community. © 2017 American Association for Clinical Chemistry.

Neurotrophic factor intervention restores auditory function in deafened animals

NASA Astrophysics Data System (ADS)

Shinohara, Takayuki; Bredberg, Göran; Ulfendahl, Mats; Pyykkö, Ilmari; Petri Olivius, N.; Kaksonen, Risto; Lindström, Bo; Altschuler, Richard; Miller, Josef M.

2002-02-01

A primary cause of deafness is damage of receptor cells in the inner ear. Clinically, it has been demonstrated that effective functionality can be provided by electrical stimulation of the auditory nerve, thus bypassing damaged receptor cells. However, subsequent to sensory cell loss there is a secondary degeneration of the afferent nerve fibers, resulting in reduced effectiveness of such cochlear prostheses. The effects of neurotrophic factors were tested in a guinea pig cochlear prosthesis model. After chemical deafening to mimic the clinical situation, the neurotrophic factors brain-derived neurotrophic factor and an analogue of ciliary neurotrophic factor were infused directly into the cochlea of the inner ear for 26 days by using an osmotic pump system. An electrode introduced into the cochlea was used to elicit auditory responses just as in patients implanted with cochlear prostheses. Intervention with brain-derived neurotrophic factor and the ciliary neurotrophic factor analogue not only increased the survival of auditory spiral ganglion neurons, but significantly enhanced the functional responsiveness of the auditory system as measured by using electrically evoked auditory brainstem responses. This demonstration that neurotrophin intervention enhances threshold sensitivity within the auditory system will have great clinical importance for the treatment of deaf patients with cochlear prostheses. The findings have direct implications for the enhancement of responsiveness in deafferented peripheral nerves.

Learning to consult with computers.

PubMed

Liaw, S T; Marty, J J

2001-07-01

To develop and evaluate a strategy to teach skills and issues associated with computers in the consultation. An overview lecture plus a workshop before and a workshop after practice placements, during the 10-week general practice (GP) term in the 5th year of the University of Melbourne medical course. Pre- and post-intervention study using a mix of qualitative and quantitative methods within a strategic evaluation framework. Self-reported attitudes and skills with clinical applications before, during and after the intervention. Most students had significant general computer experience but little in the medical area. They found the workshops relevant, interesting and easy to follow. The role-play approach facilitated students' learning of relevant communication and consulting skills and an appreciation of issues associated with using the information technology tools in simulated clinical situations to augment and complement their consulting skills. The workshops and exposure to GP systems were associated with an increase in the use of clinical software, more realistic expectations of existing clinical and medical record software and an understanding of the barriers to the use of computers in the consultation. The educational intervention assisted students to develop and express an understanding of the importance of consulting and communication skills in teaching and learning about medical informatics tools, hardware and software design, workplace issues and the impact of clinical computer systems on the consultation and patient care.

Diagnostic accuracy in Family Medicine residents using a clinical decision support system (DXplain): a randomized-controlled trial.

PubMed

Martinez-Franco, Adrian Israel; Sanchez-Mendiola, Melchor; Mazon-Ramirez, Juan Jose; Hernandez-Torres, Isaias; Rivero-Lopez, Carlos; Spicer, Troy; Martinez-Gonzalez, Adrian

2018-05-07

Clinical reasoning is an essential skill in physicians, required to address the challenges of accurate patient diagnoses. The goal of the study was to compare the diagnostic accuracy in Family Medicine residents, with and without the use of a clinical decision support tool (DXplain http://www.mghlcs.org/projects/dxplain). A total of 87 first-year Family Medicine residents, training at the National Autonomous University of Mexico (UNAM) Postgraduate Studies Division in Mexico City, participated voluntarily in the study. They were randomized to a control group and an intervention group that used DXplain. Both groups solved 30 clinical diagnosis cases (internal medicine, pediatrics, gynecology and emergency medicine) in a multiple-choice question test that had validity evidence. The percent-correct score in the Diagnosis Test in the control group (44 residents) was 74.1±9.4 (mean±standard deviation) whereas the DXplain intervention group (43 residents) had a score of 82.4±8.5 (p<0.001). There were significant differences in the four knowledge content areas of the test. Family Medicine residents have appropriate diagnostic accuracy that can improve with the use of DXplain. This could help decrease diagnostic errors, improve patient safety and the quality of medical practice. The use of clinical decision support systems could be useful in educational interventions and medical practice.

Topical rapamycin combined with pulsed dye laser in the treatment of capillary vascular malformations in Sturge-Weber syndrome: phase II, randomized, double-blind, intraindividual placebo-controlled clinical trial.

PubMed

Marqués, Laura; Núñez-Córdoba, Jorge M; Aguado, Leyre; Pretel, Maider; Boixeda, Pablo; Nagore, Eduardo; Baselga, Eulalia; Redondo, Pedro

2015-01-01

Sturge-Weber syndrome (SWS) is characterized by port-wine stains (PWS) affecting the face, eyes, and central nervous system. Pulsed dye laser (PDL) is the standard treatment for PWS. Unfortunately, recurrence is frequent because of reformation and reperfusion of blood vessels. We sought to assess the clinical efficacy of topical rapamycin combined with PDL in PWS of patients with SWS. We conducted a phase II, randomized, double-blind, intraindividual placebo-controlled, clinical trial. We recruited 23 patients with SWS and facial PWS (12 women; median age 33 years, age range 17-65 years) from the University Clinic of Navarra, Spain. Four interventions were evaluated: placebo, PDL + placebo, rapamycin, and PDL + rapamycin. Clinical and histologic responses were evaluated using a chromatographic computerized system, spectrometry, and histologic analyses at 6, 12, and 18 weeks after the intervention. PDL + rapamycin yielded the lowest digital photographic image score and the lowest percentage of vessels in histologic analysis, and showed a statistically significant improvement compared with the other interventions. The treatment was generally well tolerated. PDL was only applied to the lateral parts of the PWS area. Topical rapamycin associated with PDL seems to be an effective treatment for PWS in patients with SWS. Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Clinical Reasoning in the Assessment and Planning for Intervention for Autism Spectrum Disorder

ERIC Educational Resources Information Center

McCrimmon, Adam W.; Yule, Ashleigh E.

2017-01-01

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder whose incidence is rising. School-based professionals are in an ideal position to provide the much-needed assessment and intervention supports for students with ASD, as the professionals' placement within a formal system affords the opportunity to observe and support children…

Benefits of an automatic patient dose registry system for interventional radiology and cardiology at five hospitals of the Madrid area.

PubMed

Fernandez-Soto, J M; Ten, J I; Sanchez, R M; España, M; Pifarre, X; Vano, E

2015-07-01

The purpose of this article is to present the results of connecting the interventional radiology and cardiology laboratories of five university hospitals to a unique server using an automatic patient dose registry system (Dose On Line for Interventional Radiology, DOLIR) developed in-house, and to evaluate its feasibility more than a year after its introduction. The system receives and stores demographic and dosimetric parameters included in the MPPS DICOM objects sent by the modalities to a database. A web service provides a graphical interface to analyse the information received. During 2013, the system processed 10 788 procedures (6874 cardiac, 2906 vascular and 1008 neuro interventional). The percentages of patients requiring clinical follow-up due to potential tissue reactions before and after the use of DOLIR are presented. The system allowed users to verify in real-time, if diagnostic (or interventional) reference levels are fulfilled. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effect of health information technology interventions on lipid management in clinical practice: a systematic review of randomized controlled trials.

PubMed

Aspry, Karen E; Furman, Roy; Karalis, Dean G; Jacobson, Terry A; Zhang, Audrey M; Liptak, Gregory S; Cohen, Jerome D

2013-01-01

Large gaps in lipid treatment and medication adherence persist in high-risk outpatients in the United States. Health information technology (HIT) is being applied to close quality gaps in chronic illness care, but its utility for lipid management has not been widely studied. To perform a qualitative review of the impact of HIT interventions on lipid management processes of care (screening or testing; drug initiation, titration or adherence; or referrals) or clinical outcomes (percent at low density lipoprotein cholesterol goal; absolute lipid levels; absolute risk scores; or cardiac hospitalizations) in outpatients with coronary heart disease or at increased risk. PubMed and Google Scholar databases were searched using Medical Subject Headings related to clinical informatics and cholesterol or lipid management. English language articles that described a randomized controlled design, tested at least one HIT tool in high risk outpatients, and reported at least 1 lipid management process measure or clinical outcome, were included. Thirty-four studies that enrolled 87,874 persons were identified. Study ratings, outcomes, and magnitude of effects varied widely. Twenty-three trials reported a significant positive effect from a HIT tool on lipid management, but only 14 showed evidence that HIT interventions improve clinical outcomes. There was mixed evidence that provider-level computerized decision support improves outcomes. There was more evidence in support of patient-level tools that provide connectivity to the healthcare system, as well as system-level interventions that involve database monitoring and outreach by centralized care teams. Randomized controlled trials show wide variability in the effects of HIT on lipid management outcomes. Evidence suggests that multilevel HIT approaches that target not only providers but include patients and systems approaches will be needed to improve lipid treatment, adherence and quality. Copyright © 2013 National Lipid Association. Published by Elsevier Inc. All rights reserved.

Facility-level intervention to improve attendance and adherence among patients on anti-retroviral treatment in Kenya--a quasi-experimental study using time series analysis.

PubMed

Boruett, Patrick; Kagai, Dorine; Njogo, Susan; Nguhiu, Peter; Awuor, Christine; Gitau, Lillian; Chalker, John; Ross-Degnan, Dennis; Wahlström, Rolf; Tomson, Göran

2013-07-01

Achieving high rates of adherence to antiretroviral therapy (ART) in resource-poor settings comprises serious, but different, challenges in both the first months of treatment and during the life-long maintenance phase. We measured the impact of a health system-oriented, facility-based intervention to improve clinic attendance and patient adherence. This was a quasi-experimental, longitudinal, controlled intervention study using interrupted time series analysis. The intervention consisted of (1) using a clinic appointment diary to track patient attendance and monitor monthly performance; (2) changing the mode of asking for self-reported adherence; (3) training staff on adherence concepts, intervention methods, and use of monitoring data; (4) conducting visits to support facility teams with the implementation.We conducted the study in 12 rural district hospitals (6 intervention, 6 control) in Kenya and randomly selected 1894 adult patients over 18 years of age in two cohorts: experienced patients on treatment for at least one year, and newly treated patients initiating ART during the study. Outcome measures were: attending the clinic on or before the date of a scheduled appointment, attending within 3 days of a scheduled appointment, reporting perfect adherence, and experiencing a gap in medication supply of more than 14 days. Among experienced patients, the percentage attending the clinic on or before a scheduled appointment increased in both level (average total increase immediately after intervention) (+5.7%; 95% CI=2.1, 9.3) and trend (increase per month) (+1.0% per month; 95% CI=0.6, 1.5) following the intervention, as did the level and trend of those keeping appointments within three days (+4.2%; 95% CI=1.6, 6.7; and +0.8% per month; 95% CI=0.6, 1.1, respectively). The relative difference between the intervention and control groups based on the monthly difference in visit rates increased significantly in both level (+6.5; 95% CI=1.4, 11.6) and trend (1.0% per month; 95% CI=0.2, 1.8) following the intervention for experienced patients attending the clinic within 3 days of their scheduled appointments.The decrease in the percentage of experienced patients with a medication gap greater than 14 days approached statistical significance (-11.3%; 95% CI=-22.7, 0.1), and the change seemed to persist over 11 months after the intervention. All facility staff used appointment-keeping data to calculate adherence and discussed outcomes regularly. The appointment-tracking system and monthly performance monitoring was strengthened, and patient attendance was improved. Scale-up to national level may be considered.

Assessment of Clinical Pharmacy Interventions to Reduce Outpatient Use of High-Risk Medications in the Elderly.

PubMed

Weddle, Sarah C; Rowe, A Shaun; Jeter, Julie W; Renwick, Rachel C; Chamberlin, Shaunta' M; Franks, Andrea S

2017-05-01

Use of high-risk medications in the elderly (HRME) and drug-disease (Rx-DIS) interactions in the elderly, as defined by the Healthcare Effectiveness Data and Information Set (HEDIS) Measures, are significantly associated with mortality, hospital admission, and need for emergency care. No published studies to date evaluate interventions to reduce the use of HEDIS-defined HRME, although many studies have postulated a beneficial effect of such interventions. To evaluate the effect of pharmacist interventions on use of HRME and Rx-DIS interactions in the outpatient elderly population. This retrospective cohort study was conducted in a resident-based family medicine clinic. Patients aged ≥ 65 years were prospectively screened for the use of HRME and Rx-DIS interactions before their visits with their primary care providers. If HRME or Rx-DIS interactions were noted, the clinical pharmacist sent messages to the physicians through the electronic medical record, alerting them of the findings with suggestions of safer alternative agents, if applicable. The recommendation acceptance rate was assessed and then compared with a historical control from a similar time frame. The primary outcome was assessed with a chi square analysis. Secondary outcomes were assessed with descriptive statistics, chi square test, and Fisher's exact test. HRME and/or Rx-DIS interactions were changed 25.9% of the time in the pharmacist intervention group compared with only 2.0% of the time in the historical control group (P = 0.001). The most frequently changed medication classes included skeletal muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs. Over 85% of the medication changes were preserved at the end of the study period. There was no difference between groups in the number of patients with HRME or Rx-DIS interactions. Clinical pharmacy interventions result in significant reductions in use of HRME and Rx-DIS interactions in the outpatient elderly population. Using electronic communication allows pharmacists to provide meaningful interventions for numerous patients receiving care in a high-volume family medicine clinic setting. There was no funding or sponsorship for this study. Rowe reports personal fees from The Medicines Company, outside the submitted work. The other authors have nothing to disclose. Study concept and design were contributed by Jeter, Chamberlin, and Weddle, with assistance from Rowe and Franks. Weddle and Renwick collected the data, and data interpretation was performed by Weddle and Rowe, with assistance from Franks. The manuscript was written by Weddle and Rowe and revised by Weddle and Franks, assisted by Chamberlin. The abstract for the completed study was presented at the American College of Clinical Pharmacy Global Conference, San Francisco, California, October 2015, and the Southeastern Residency Conference, Athens, Georgia, April 2015 (platform presentation). The research-in-progress abstract was presented at the Tennessee Society of Health System Pharmacists, Nashville, Tennessee, February 2015; the American Society of Health System Pharmacists Midyear Clinical Meeting, Anaheim, California, December 2014; and the University HealthSystem Consortium Pharmacy Council, Anaheim, California, December 2014.

International collaboration in health promotion and disease management: implications of U.S. health promotion efforts on Japan's health care system.

PubMed

Pelletier, Kenneth R

2005-01-01

For more than 25 years, health promotion and disease management interventions have been conducted by large employers in the United States. Today there are more than 100 studies of such multifactorial, comprehensive interventions that all demonstrate positive clinical outcomes. For those interventions that have also been evaluated for return on investment, all but one have demonstrated cost-effectiveness. This article is an evidence-based overview of the clinical and cost outcomes research to elaborate on the insights gained from this research in the areas of implementation and evaluation of such programs; integration of health promotion and disease management programs into conventional, occupational medicine; accessing difficult to reach populations, such as mobile workers, retirees, and/or dependents; areas of potential conflict of interest and privacy/confidentiality issues; health consequences of downsizing and job strain; and, finally, recommendations for improved integration and evaluation of such programs for both clinical and cost outcomes. With medical costs rapidly escalating again on a global scale, these interventions with evidence of both clinical and cost outcomes can provide the foundation to improve the health, performance, and productivity of both individuals and their corporations.

Coding and Billing in Surgical Education: A Systems-Based Practice Education Program.

PubMed

Ghaderi, Kimeya F; Schmidt, Scott T; Drolet, Brian C

Despite increased emphasis on systems-based practice through the Accreditation Council for Graduate Medical Education core competencies, few studies have examined what surgical residents know about coding and billing. We sought to create and measure the effectiveness of a multifaceted approach to improving resident knowledge and performance of documenting and coding outpatient encounters. We identified knowledge gaps and barriers to documentation and coding in the outpatient setting. We implemented a series of educational and workflow interventions with a group of 12 residents in a surgical clinic at a tertiary care center. To measure the effect of this program, we compared billing codes for 1 year before intervention (FY2012) to prospectively collected data from the postintervention period (FY2013). All related documentation and coding were verified by study-blinded auditors. Interventions took place at the outpatient surgical clinic at Rhode Island Hospital, a tertiary-care center. A cohort of 12 plastic surgery residents ranging from postgraduate year 2 through postgraduate year 6 participated in the interventional sequence. A total of 1285 patient encounters in the preintervention group were compared with 1170 encounters in the postintervention group. Using evaluation and management codes (E&M) as a measure of documentation and coding, we demonstrated a significant and durable increase in billing with supporting clinical documentation after the intervention. For established patient visits, the monthly average E&M code level increased from 2.14 to 3.05 (p < 0.01); for new patients the monthly average E&M level increased from 2.61 to 3.19 (p < 0.01). This study describes a series of educational and workflow interventions, which improved resident coding and billing of outpatient clinic encounters. Using externally audited coding data, we demonstrate significantly increased rates of higher complexity E&M coding in a stable patient population based on improved documentation and billing awareness by the residents. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN)

PubMed Central

English, Joey D.; Yavagal, Dileep R.; Gupta, Rishi; Janardhan, Vallabh; Zaidat, Osama O.; Xavier, Andrew R.; Nogueira, Raul G.; Kirmani, Jawad F.; Jovin, Tudor G.

2016-01-01

Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients. PMID:27051410

A system to improve medication safety in the setting of acute kidney injury: initial provider response.

PubMed

McCoy, Allison B; McCoy, Allison Beck; Peterson, Josh F; Gadd, Cynthia S; Gadd, Cindy; Danciu, Ioana; Waitman, Lemuel R

2008-11-06

Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for nephrotoxic or renally cleared drugs. We developed a comprehensive medication safety intervention with varying levels of workflow intrusiveness within computerized provider order entry to continuously monitor for and alert providers about early-onset acute kidney injury. Initial provider response to the interventions shows potential success in improving medication safety and suggests future enhancements to increase effectiveness.

Skin dose mapping for fluoroscopically guided interventions.

PubMed

Johnson, Perry B; Borrego, David; Balter, Stephen; Johnson, Kevin; Siragusa, Daniel; Bolch, Wesley E

2011-10-01

To introduce a new skin dose mapping software system for interventional fluoroscopy dose assessment and to analyze the benefits and limitations of patient-phantom matching. In this study, a new software system was developed for visualizing patient skin dose during interventional fluoroscopy procedures. The system works by translating the reference point air kerma to the location of the patient's skin, which is represented by a computational model. In order to orient the model with the x-ray source, geometric parameters found within the radiation dose structured report (RDSR) are used along with a limited number of in-clinic measurements. The output of the system is a visual indication of skin dose mapped onto an anthropomorphic model at a resolution of 5 mm. In order to determine if patient-dependent and patient-sculpted models increase accuracy, peak skin dose was calculated for each of 26 patient-specific models and compared with doses calculated using an elliptical stylized model, a reference hybrid model, a matched patient-dependent model and one patient-sculpted model. Results were analyzed in terms of a percent difference using the doses calculated using the patient-specific model as the true standard. Anthropometric matching, including the use of both patient-dependent and patient-sculpted phantoms, was shown most beneficial for left lateral and anterior-posterior projections. In these cases, the percent difference using a reference model was between 8 and 20%, using a patient-dependent model between 7 and 15%, and using a patient-sculpted model between 3 and 7%. Under the table tube configurations produced errors less than 5% in most situations due to the flattening affects of the table and pad, and the fact that table height is the main determination of source-to-skin distance for these configurations. In addition to these results, several skin dose maps were produced and a prototype display system was placed on the in-clinic monitor of an interventional fluoroscopy system. The skin dose mapping program developed in this work represents a new tool that, as the RDSR becomes available through automated export or real-time streaming, can provide the interventional physician information needed to modify behavior when clinically appropriate. The program is nonproprietary and transferable, and also functions independent to the software systems already installed on the control room workstation. The next step will be clinical implementation where the workflow will be optimized along with further analysis of real-time capabilities.

Knowledge-based nursing diagnosis

NASA Astrophysics Data System (ADS)

Roy, Claudette; Hay, D. Robert

1991-03-01

Nursing diagnosis is an integral part of the nursing process and determines the interventions leading to outcomes for which the nurse is accountable. Diagnoses under the time constraints of modern nursing can benefit from a computer assist. A knowledge-based engineering approach was developed to address these problems. A number of problems were addressed during system design to make the system practical extended beyond capture of knowledge. The issues involved in implementing a professional knowledge base in a clinical setting are discussed. System functions, structure, interfaces, health care environment, and terminology and taxonomy are discussed. An integrated system concept from assessment through intervention and evaluation is outlined.

Systems consultation: protocol for a novel implementation strategy designed to promote evidence-based practice in primary care.

PubMed

Quanbeck, Andrew; Brown, Randall T; E Zgierska, Aleksandra; A Johnson, Roberta; Robinson, James M; Jacobson, Nora

2016-01-27

Adoption of evidence-based practices takes place at a glacial place in healthcare. This research will pilot test an innovative implementation strategy - systems consultation -intended to speed the adoption of evidence-based practice in primary care. The strategy is based on tenets of systems engineering and has been extensively tested in addiction treatment. Three innovations have been included in the strategy - translation of a clinical practice guideline into a checklist-based implementation guide, the use of physician peer coaches ('systems consultants') to help clinics implement the guide, and a focus on reducing variation in practices across prescribers and clinics. The implementation strategy will be applied to improving opioid prescribing practices in primary care, which may help ultimately mitigate the increasing prevalence of opioid abuse and addiction. The pilot test will compare four intervention clinics to four control clinics in a matched-pairs design. A leading clinical guideline for opioid prescribing has been translated into a checklist-based implementation guide in a systematic process that involved experts who wrote the guideline in consultation with implementation experts and primary care physicians. Two physicians with expertise in family and addiction medicine are serving as the systems consultants. Each systems consultant will guide two intervention clinics, using two site visits and follow-up communication by phone and email, to implement the translated guideline. Mixed methods will be used to test the feasibility, acceptability, and preliminary effectiveness of the implementation strategy in an evaluation that meets standards for 'fully developed use' of the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). The clinic will be the primary unit of analysis. The systems consultation implementation strategy is intended to generalize to the adoption of other clinical guidelines. This pilot test is intended to prepare for a large randomized clinical trial that will test the strategy against other implementation strategies, such as audit/feedback and academic detailing, used to close the gap between knowledge and practice. The systems consultation approach has the potential to shorten the famously long time it takes to implement evidence-based practices and clinical guidelines in healthcare.

Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial.

PubMed

Crowley, Matthew J; Edelman, David; McAndrew, Ann T; Kistler, Susan; Danus, Susanne; Webb, Jason A; Zanga, Joseph; Sanders, Linda L; Coffman, Cynthia J; Jackson, George L; Bosworth, Hayden B

2016-05-01

Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment. We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure. At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups. A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.

Flexible robotic catheters in the visceral segment of the aorta: advantages and limitations.

PubMed

Li, Mimi M; Hamady, Mohamad S; Bicknell, Colin D; Riga, Celia V

2018-06-01

Flexible robotic catheters are an emerging technology which provide an elegant solution to the challenges of conventional endovascular intervention. Originally developed for interventional cardiology and electrophysiology procedures, remotely steerable robotic catheters such as the Magellan system enable greater precision and enhanced stability during target vessel navigation. These technical advantages facilitate improved treatment of disease in the arterial tree, as well as allowing execution of otherwise unfeasible procedures. Occupational radiation exposure is an emerging concern with the use of increasingly complex endovascular interventions. The robotic systems offer an added benefit of radiation reduction, as the operator is seated away from the radiation source during manipulation of the catheter. Pre-clinical studies have demonstrated reduction in force and frequency of vessel wall contact, resulting in reduced tissue trauma, as well as improved procedural times. Both safety and feasibility have been demonstrated in early clinical reports, with the first robot-assisted fenestrated endovascular aortic repair in 2013. Following from this, the Magellan system has been used to successfully undertake a variety of complex aortic procedures, including fenestrated/branched endovascular aortic repair, embolization, and angioplasty.

Provider Agency Practices as a Source of Social Work EBP.

PubMed

Blakely, Thomas J; Dziadosz, Gregory M

2016-01-01

Through this article the authors propose that agency service provider systems may be a source of evidence-based practices (EBP). One agency's design and implementation of a program entitled Community Treatment and Rehabilitation is presented as an example. The elements of this program conform to the creation of EBPs. It was formulated with consideration of clients' values and judgments through their participation at every step in the assessment and treatment process. Staff clinicians were trained in established EBP interventions, such as cognitive therapy, embedded in a system of ordered assessment, treatment, and outcome evaluation. A controlled research design was used to gather outcome data to inform clinicians' decisions about interventions that were then systematically applied with clients. The delivery system was organized for clinical supervisors to guide staff clinical practices so that all were operating on the same set of guidelines allowing for similar outcomes to occur with similar interventions. This method of developing EBPs makes them available for application immediately and successfully eliminates the delay between development and implementation that usually occurs with other sources of EBPs.

Comprehensive assessment of patient image quality and radiation dose in latest generation cardiac x-ray equipment for percutaneous coronary interventions

PubMed Central

Gislason-Lee, Amber J.; Keeble, Claire; Egleston, Daniel; Bexon, Josephine; Kengyelics, Stephen M.; Davies, Andrew G.

2017-01-01

Abstract. This study aimed to determine whether a reduction in radiation dose was found for percutaneous coronary interventional (PCI) patients using a cardiac interventional x-ray system with state-of-the-art image enhancement and x-ray optimization, compared to the current generation x-ray system, and to determine the corresponding impact on clinical image quality. Patient procedure dose area product (DAP) and fluoroscopy duration of 131 PCI patient cases from each x-ray system were compared using a Wilcoxon test on median values. Significant reductions in patient dose (p≪0.001) were found for the new system with no significant change in fluoroscopy duration (p=0.2); procedure DAP reduced by 64%, fluoroscopy DAP by 51%, and “cine” acquisition DAP by 76%. The image quality of 15 patient angiograms from each x-ray system (30 total) was scored by 75 clinical professionals on a continuous scale for the ability to determine the presence and severity of stenotic lesions; image quality scores were analyzed using a two-sample t-test. Image quality was reduced by 9% (p≪0.01) for the new x-ray system. This demonstrates a substantial reduction in patient dose, from acquisition more than fluoroscopy imaging, with slightly reduced image quality, for the new x-ray system compared to the current generation system. PMID:28491907

Economic evaluation of a pharmaceutical care program for elderly diabetic and hypertensive patients in primary health care: a 36-month randomized controlled clinical trial.

PubMed

Obreli-Neto, Paulo Roque; Marusic, Srecko; Guidoni, Camilo Molino; Baldoni, André de Oliveira; Renovato, Rogério Dias; Pilger, Diogo; Cuman, Roberto Kenji Nakamura; Pereira, Leonardo Régis Leira

2015-01-01

Most diabetic and hypertensive patients, principally the elderly, do not achieve adequate disease control and consume 5%-15% of annual health care budgets. Previous studies verified that pharmaceutical care is useful for achieving adequate disease control in diabetes and hypertension. To evaluate the economic cost and the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) of pharmaceutical care in the management of diabetes and hypertension in elderly patients in a primary public health care system in a developing country. A 36-month randomized controlled clinical trial was performed with 200 patients who were divided into a control group (n = 100) and an intervention group (n = 100). The control group received the usual care offered by the Primary Health Care Unit (medical and nurse consultations). The intervention group received the usual care plus a pharmaceutical care intervention. The intervention and control groups were compared with regard to the direct costs of health services (i.e., general practitioner, specialist, nurse, and pharmacist appointments; emergency room visits; and drug therapy costs) and the ICER per QALY. These evaluations used the health system perspective. No statistically significant difference was found between the intervention and control groups in total direct health care costs ($281.97 ± $49.73 per patient vs. $212.28 ± $43.49 per patient, respectively; P = 0.089); pharmaceutical care added incremental costs of $69.60 (± $7.90) per patient. The ICER per QALY was $53.50 (95% CI = $51.60-$54.00; monetary amounts are given in U.S. dollars). Every clinical parameter evaluated improved for the pharmaceutical care group, whereas these clinical parameters remained unchanged in the usual care group. The difference in differences (DID) tests indicated that for each clinical parameter, the patients in the intervention group improved more from pre to post than the control group (P < 0.001). While pharmaceutical care did not significantly increase total direct health care costs, significantly improved health outcomes were seen. The mean ICER per QALY gained suggests a favorable cost-effectiveness.

Mental health pharmacists as interim prescribers

PubMed Central

2017-01-01

Introduction: Turnover leading to fluctuations in prescriber availability presents many challenges, most notably in access to and continuity of care. In 2015, the Veterans Affairs Eastern Colorado Healthcare System (VA ECHCS) experienced a period of significant mental health prescriber turnover leading to patient utilization of psychiatric emergency services (PES) for nonemergent medication management. The resulting increase in volume placed excessive stress on PES prescribers. Mental health pharmacists have opportunities to provide interim medication management while patients are between prescribers. Methods: This study was a retrospective, cohort study of patients unassigned to an outpatient mental health prescriber due to prescriber turnover, receiving care at VA ECHCS between October 1, 2015, and February 28, 2016. The primary outcome was the number of pharmacist interventions performed. Secondary outcomes characterize the interventions performed and describe the change in the mean monthly volume of patients presenting to PES. Results: In this veteran population, 152 interventions were performed in 81 unique patients. The most common intervention was prescription renewals (80%). Interventions most commonly involved antidepressants (28%), antipsychotics (10%), and mood stabilizers (10%). Before initiation of the clinic, Denver VA PES experienced a mean of 300 monthly visits. After clinic implementation, PES visits decreased significantly to a mean of 237 visits per month (P = .041). Discussion: The pharmacist interim prescriber clinic was associated with a significant decrease in mean number of patients seen per month in PES. The success of the clinic also contributed to interest by the mental health service to expand clinical pharmacy services.

A qualitative study of contextual factors' impact on measures to reduce surgery cancellations.

PubMed

Hovlid, Einar; Bukve, Oddbjørn

2014-05-13

Contextual factors influence quality improvement outcomes. Understanding this influence is important when adapting and implementing interventions and translating improvements into new settings. To date, there is limited knowledge about how contextual factors influence quality improvement processes. In this study, we explore how contextual factors affected measures to reduce surgery cancellations, which are a persistent problem in healthcare. We discuss the usefulness of the theoretical framework provided by the model for understanding success in quality (MUSIQ) for this kind of research. We performed a qualitative case study at Førde Hospital, Norway, where we had previously demonstrated a reduction in surgery cancellations. We interviewed 20 clinicians and performed content analysis to explore how contextual factors affected measures to reduce cancellations of planned surgeries. We identified three common themes concerning how contextual factors influenced the change process: 1) identifying a need to change, 2) facilitating system-wide improvement, and 3) leader involvement and support. Input from patients helped identify a need to change and contributed to the consensus that change was necessary. Reducing cancellations required improving the clinical system. This improvement process was based on a strategy that emphasized the involvement of frontline clinicians in detecting and improving system problems. Clinicians shared information about their work by participating in improvement teams to develop a more complete understanding of the clinical system and its interdependencies. This new understanding allowed clinicians to detect system problems and design adequate interventions. Middle managers' participation in the improvement teams and in regular work processes was important for successfully implementing and adapting interventions. Contextual factors interacted with one another and with the interventions to facilitate changes in the clinical system, reducing surgery cancellations. The MUSIQ framework is useful for exploring how contextual factors influence the improvement process and how they influence one another. Discussing data in relation to a theoretical framework can promote greater uniformity in reporting findings, facilitating knowledge-building across studies.

The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes

PubMed Central

Maruthur, Nisa; Mathioudakis, Nestoras; Spanakis, Elias; Rubin, Daniel; Zilbermint, Mihail; Hill-Briggs, Felicia

2017-01-01

Purpose of Review The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes. Recent Findings Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Summary Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies. PMID:28567711

Optimizing chronic disease management mega-analysis: economic evaluation.

PubMed

2013-01-01

As Ontario's population ages, chronic diseases are becoming increasingly common. There is growing interest in services and care models designed to optimize the management of chronic disease. To evaluate the cost-effectiveness and expected budget impact of interventions in chronic disease cohorts evaluated as part of the Optimizing Chronic Disease Management mega-analysis. Sector-specific costs, disease incidence, and mortality were calculated for each condition using administrative databases from the Institute for Clinical Evaluative Sciences. Intervention outcomes were based on literature identified in the evidence-based analyses. Quality-of-life and disease prevalence data were obtained from the literature. Analyses were restricted to interventions that showed significant benefit for resource use or mortality from the evidence-based analyses. An Ontario cohort of patients with each chronic disease was constructed and followed over 5 years (2006-2011). A phase-based approach was used to estimate costs across all sectors of the health care system. Utility values identified in the literature and effect estimates for resource use and mortality obtained from the evidence-based analyses were applied to calculate incremental costs and quality-adjusted life-years (QALYs). Given uncertainty about how many patients would benefit from each intervention, a system-wide budget impact was not determined. Instead, the difference in lifetime cost between an individual-administered intervention and no intervention was presented. Of 70 potential cost-effectiveness analyses, 8 met our inclusion criteria. All were found to result in QALY gains and cost savings compared with usual care. The models were robust to the majority of sensitivity analyses undertaken, but due to structural limitations and time constraints, few sensitivity analyses were conducted. Incremental cost savings per patient who received intervention ranged between $15 per diabetic patient with specialized nursing to $10,665 per patient wth congestive heart failure receiving in-home care. Evidence used to inform estimates of effect was often limited to a single trial with limited generalizability across populations, interventions, and health care systems. Because of the low clinical fidelity of health administrative data sets, intermediate clinical outcomes could not be included. Cohort costs included an average of all health care costs and were not restricted to costs associated with the disease. Intervention costs were based on resource use specified in clinical trials. Applying estimates of effect from the evidence-based analyses to real-world resource use resulted in cost savings for all interventions. On the basis of quality-of-life data identified in the literature, all interventions were found to result in a greater QALY gain than usual care would. Implementation of all interventions could offer significant cost reductions. However, this analysis was subject to important limitations. Chronic diseases are the leading cause of death and disability in Ontario. They account for a third of direct health care costs across the province. This study aims to evaluate the cost-effectiveness of health care interventions that might improve the management of chronic diseases. The evaluated interventions led to lower costs and better quality of life than usual care. Offering these options could reduce costs per patient. However, the studies used in this analysis were of medium to very low quality, and the methods had many limitations.

Registry Assessment of Peripheral Interventional Devices (RAPID)　- Registry Assessment of Peripheral Interventional Devices Core Data Elements.

PubMed

Jones, W Schuyler; Krucoff, Mitchell W; Morales, Pablo; Wilgus, Rebecca W; Heath, Anne H; Williams, Mary F; Tcheng, James E; Marinac-Dabic, J Danica; Malone, Misti L; Reed, Terrie L; Fukaya, Rie; Lookstein, Robert; Handa, Nobuhiro; Aronow, Herbert D; Bertges, Daniel J; Jaff, Michael R; Tsai, Thomas T; Smale, Joshua A; Zaugg, Margo J; Thatcher, Robert J; Cronenwett, Jack L; Nc, Durham; Md, Silver Spring; Japan, Tokyo; Ny, New York; Ri, Providence; Vt, Burlington; Mass, Newton; Colo, Denver; Ariz, Tempe; Calif, Santa Clara; Minn, Minneapolis; Nh, Lebanon

2018-01-25

The current state of evaluating patients with peripheral artery disease and more specifically of evaluating medical devices used for peripheral vascular intervention (PVI) remains challenging because of the heterogeneity of the disease process, the multiple physician specialties that perform PVI, the multitude of devices available to treat peripheral artery disease, and the lack of consensus about the best treatment approaches. Because PVI core data elements are not standardized across clinical care, clinical trials, and registries, aggregation of data across different data sources and physician specialties is currently not feasible.Methods and Results:Under the auspices of the U.S. Food and Drug Administration's Medical Device Epidemiology Network initiative-and its PASSION (Predictable and Sustainable Implementation of the National Registries) program, in conjunction with other efforts to align clinical data standards-the Registry Assessment of Peripheral Interventional Devices (RAPID) workgroup was convened. RAPID is a collaborative, multidisciplinary effort to develop a consensus lexicon and to promote interoperability across clinical care, clinical trials, and national and international registries of PVI. The current manuscript presents the initial work from RAPID to standardize clinical data elements and definitions, to establish a framework within electronic health records and health information technology procedural reporting systems, and to implement an informatics-based approach to promote the conduct of pragmatic clinical trials and registry efforts in PVI. Ultimately, we hope this work will facilitate and improve device evaluation and surveillance for patients, clinicians, health outcomes researchers, industry, policymakers, and regulators.

Increased patient communication using a process supplementing an electronic medical record.

PubMed

Garvey, Thomas D; Evensen, Ann E

2015-02-01

Importance: Patients with cervical cytology abnormalities may require surveillance for many years, which increases the risk of management error, especially in clinics with multiple managing clinicians. National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) certification requires tracking of abnormal results and communicating effectively with patients. The purpose of this study was to determine whether a computer-based tracking system that is not embedded in the electronic medical record improves (1) accurate and timely communication of results and (2) patient adherence to follow-up recommendations. Design: Pre/post study using data from 2005-2012. Intervention implemented in 2008. Data collected via chart review for at least 18 months after index result. Participants: Pre-intervention: all women (N = 72) with first abnormal cytology result from 2005-2007. Post-intervention: all women (N = 128) with first abnormal cytology result from 2008-2010. Patients were seen at a suburban, university-affiliated, family medicine residency clinic. Intervention: Tracking spreadsheet reviewed monthly with reminders generated for patients not in compliance with recommendations. Main Outcome and Measures: (1) rates of accurate and timely communication of results and (2) rates of patient adherence to follow-up recommendations. Intervention decreased absent or erroneous communication from clinician to patient (6.4% pre- vs 1.6% post-intervention [P = 0.04]), but did not increase patient adherence to follow-up recommendations (76.1% pre- vs 78.0% post-intervention [ P= 0.78]). Use of a spreadsheet tracking system improved communication of abnormal results to patients, but did not significantly improve patient adherence to recommended care. Although the tracking system complies with NCQA PCMH requirements, it was insufficient to make meaningful improvements in patient-oriented outcomes.

Developing a Multiple Caregiver Group for Caregivers of Adolescents With Disruptive Behaviors.

PubMed

Oruche, Ukamaka M; Robb, Sheri L; Aalsma, Matt; Pescosolido, Bernice; Brown-Podgorski, Brittany; Draucker, Claire Burke

2017-12-01

This article describes the development of a 6-week multiple caregiver group intervention for primary caregivers of adolescents diagnosed with Oppositional Defiant Disorder or Conduct Disorder in low-income African American families. The intervention is aimed at increasing the primary caregivers' self-efficacy in managing interactions within the family and especially with child serving educational, mental health, juvenile justice, and child welfare systems. Development of the intervention involved seven iterative activities performed in a collaborative effort between an interdisciplinary academic team, community engagement specialists, members of the targeted population, and clinical partners from a large public mental health system. The intervention development process described in this article can provide guidance for teams that aim to develop new mental health interventions that target specific outcomes in populations with unique needs. Copyright © 2017 Elsevier Inc. All rights reserved.

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study.

PubMed

Saronga, Happiness Pius; Duysburgh, Els; Massawe, Siriel; Dalaba, Maxwell Ayindenaba; Wangwe, Peter; Sukums, Felix; Leshabari, Melkizedeck; Blank, Antje; Sauerborn, Rainer; Loukanova, Svetla

2017-08-07

QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

Patient Engagement in Randomized Controlled Tai Chi Clinical Trials among the Chronically Ill.

PubMed

Jiang, Dongsheng; Kong, Weihong; Jiang, Joanna J

2017-01-01

Physicians encounter various symptom-based complaints each day. While physicians strive to support patients with chronic illnesses, evidence indicates that patients who are actively involved in their health care have better health outcomes and sometimes lowers costs. This article is to analyze how patient engagement is described when complex interventions such as Tai Chi were delivered in Randomized Controlled clinical Trials (RCTs). It reviews the dynamic patient- physician relationship in chronic illness management and to illustrate the patient engagement process, using Tai Chi as an example intervention. RCTs are considered the gold standard in clinical research. This study is a qualitative analysis of RCTs using Tai Chi as an intervention. A systematic literature search was performed to identify quality randomized controlled clinical trials that investigated the effects of Tai Chi. Selected clinical trials were classified according to research design, intervention style, patient engagement, and outcomes. Patient engagement was classified based on levels of patient participation, compliance, and selfmanagement. The chronic health conditions included in this paper are Parkinson's disease, polyneuropathy, hypertension, stroke, chronic insomnia, chronic heart failure, fibromyalgia, osteoarthritis, central obesity, depression, deconditioning in the elderly, or being pre-clinically disabled. We found that patient engagement, as a concept, was not well defined in literature. It covers a wide range of related terms, such as patient involvement, participation, shared decision- making, patient activation, adherence, compliance, and self-management. Tai Chi, as a very complex practice system, is to balance all aspects of a patient's life; however, the level of patient engagement is difficult to describe using conventional clinical trial design. To accurately illustrate the effect of a complex intervention, novel research design must explore ways to measure patient engagement in the intervention in order to clarify its specific role on health. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

SUBSTANCE USE SCREENING AND INTERVENTIONS IN DENTAL CLINICS: SURVEY OF PRACTICE-BASED RESEARCH NETWORK DENTISTS ON CURRENT PRACTICES, POLICIES, AND BARRIERS

PubMed Central

Wright, Shana; Matthews, Abigail G.; Rotrosen, John; Shelley, Donna; Buchholz, Matthew P.; Curro, Frederick A.

2013-01-01

Background Dental visits represent an opportunity to identify and assist patients with substance use, but little is known about how dentists are addressing tobacco, alcohol and illicit drugs. We surveyed dentists to learn about the role their practices might play in providing substance use screening and interventions. Methods A 41-item, web-based survey was distributed to all 210 dentists active in the PEARL dental practice-based research network. The questionnaire assessed clinic policies and current practices, attitudes, and perceived barriers to providing services for tobacco, alcohol, and illicit drug use. Results 143 dentists completed the survey (68% response rate). While screening was common, fewer were providing follow-up counseling or referrals for substance use. Insufficient knowledge/training was the most frequently cited barrier to intervention. Many dentists said they would offer assistance for tobacco (67%) or alcohol or illicit drugs (52%) if reimbursed; an affirmative response was more likely among those who saw publicly insured patients. Conclusions Dentists recognize the importance of screening for substance use, but lack clinical training and systems that could facilitate intervention. Practice Implications If barriers were reduced through changes in reimbursement, education, and systems-level support, our findings indicate that dentists may be willing to address substance use, including use of alcohol and illicit drugs as well as tobacco. PMID:23729460

Interventions for the prevention of dry socket: an evidence-based update.

PubMed

Sharif, M O; Dawoud, B E S; Tsichlaki, A; Yates, J M

2014-07-11

This paper reviews the latest evidence for local and systemic interventions for the prevention of alveolar osteitis (dry socket). Dry socket is a painful and common post-operative complication following exodontia. Any interventions for the prevention of dry socket could reduce both its incidence and help avoid this painful complication. Prophylactic measures proposed in the literature are discussed. Furthermore, this article discusses both the clinical and histological stages of a normal healing socket.

Evaluation of a multiple-encounter in situ simulation for orientation of staff to a new paediatric emergency service: a single-group pretest/post-test study

PubMed Central

Kinnear, Frances B; Fulbrook, Paul

2017-01-01

Aim To assess the utility of a multiple-encounter in-situ (MEIS) simulation as an orientation tool for multidisciplinary staff prior to opening a new paediatric emergency service. Methods A single-group pretest/post-test study was conducted. During the MEIS simulation, multidisciplinary staff with participant or observer roles managed eight children (mannequins) who attended triage with their parent/guardians (clinical facilitators) for a range of emergency presentations (structured scenarios designed to represent the expected range of presentations plus test various clinical pathways/systems). Participants were debriefed to explore clinical, systems and crisis-resource management issues. Participants also completed a pre-intervention and post-intervention questionnaire comprising statements about role confidence and orientation adequacy. Pre-test and post-test results were analysed using t-test and Wilcoxon signed rank test. Results Eighty-nine staff participated in the MEIS simulation, with the majority completing the pre-simulation and post-simulation questionnaire. There was a significant improvement in post-intervention versus pre-intervention Likert scores for role confidence and orientation adequacy (p=0.001 and <0.001, respectively); effect sizes suggested the greatest impact was on orientation adequacy. Nearly all scenarios resulted in significant increases in participants’ confidence levels. Conclusions The MEIS simulation was of utility in orientation of staff, at least with respect to self-reported role confidence and orientation adequacy. Its effectiveness in practice or compared with other orientation techniques was not assessed, but it did identify several flaws in planned systems allowing remediation prior to opening. PMID:29354279

Evaluation of a multiple-encounter in situ simulation for orientation of staff to a new paediatric emergency service: a single-group pretest/post-test study.

PubMed

Davison, Michelle; Kinnear, Frances B; Fulbrook, Paul

2017-10-01

To assess the utility of a multiple-encounter in-situ (MEIS) simulation as an orientation tool for multidisciplinary staff prior to opening a new paediatric emergency service. A single-group pretest/post-test study was conducted. During the MEIS simulation, multidisciplinary staff with participant or observer roles managed eight children (mannequins) who attended triage with their parent/guardians (clinical facilitators) for a range of emergency presentations (structured scenarios designed to represent the expected range of presentations plus test various clinical pathways/systems). Participants were debriefed to explore clinical, systems and crisis-resource management issues. Participants also completed a pre-intervention and post-intervention questionnaire comprising statements about role confidence and orientation adequacy. Pre-test and post-test results were analysed using t-test and Wilcoxon signed rank test. Eighty-nine staff participated in the MEIS simulation, with the majority completing the pre-simulation and post-simulation questionnaire. There was a significant improvement in post-intervention versus pre-intervention Likert scores for role confidence and orientation adequacy (p=0.001 and <0.001, respectively); effect sizes suggested the greatest impact was on orientation adequacy. Nearly all scenarios resulted in significant increases in participants' confidence levels. The MEIS simulation was of utility in orientation of staff, at least with respect to self-reported role confidence and orientation adequacy. Its effectiveness in practice or compared with other orientation techniques was not assessed, but it did identify several flaws in planned systems allowing remediation prior to opening.

Designing CIS to improve decisions in depression disease management: a discourse analysis of front line practice.

PubMed

Mirel, Barbara; Ackerman, Mark S; Kerber, Kevin; Klinkman, Michael

2006-01-01

Clinical care management promises to help diminish the major health problem of depression. To realize this promise, front line clinicians must know which care management interventions are best for which patients and act accordingly. Unfortunately, the detailed intervention data required for such differentiated assessments are missing in most clinical information systems (CIS). To determine frontline clinicians' needs for these data and to identify the data that CIS should keep, we conducted an 18 month ethnographic study and discourse analysis of telehealth depression care management. Results show care managers need data-based evidence to choose best options, and discourse analysis suggests some personalized interventions that CIS should and can feasibly capture for evidence.

Adherence to Treatment in Hypertension.

PubMed

Villalva, Carlos Menéndez; Alvarez-Muiño, Xosé Luís López; Mondelo, Trinidad Gamarra; Fachado, Alfonso Alonso; Fernández, Joaquín Cubiella

2017-01-01

The lack of adherence to treatment in hypertension affects approximately 30 % of patients. The elderly, those with several co-morbidities, social isolation, low incomes or depressive symptoms are the most vulnerable to this problem. There is no ideal method to quantify the adherence to the treatment. Indirect methods are recommended in clinical practice. Any intervention strategy should not blame the patient and try a collaborative approach. It is recommended to involve the patient in decision-making. The clinical interview style must be patient-centered including motivational techniques. The improvement strategies that showed greater effectiveness in the compliance of hypertension treatment were: treatment simplification, appointment reminders systems, blood pressure self-monitoring, organizational improvements and nurse and pharmacists care. The combination of different interventions are recommended against isolated interventions.

Impact of an Electronic Health Record-Integrated Personal Health Record on Patient Participation in Health Care: Development and Randomized Controlled Trial of MyHealthKeeper.

PubMed

Ryu, Borim; Kim, Nari; Heo, Eunyoung; Yoo, Sooyoung; Lee, Keehyuck; Hwang, Hee; Kim, Jeong-Whun; Kim, Yoojung; Lee, Joongseek; Jung, Se Young

2017-12-07

Personal health record (PHR)-based health care management systems can improve patient engagement and data-driven medical diagnosis in a clinical setting. The purpose of this study was (1) to demonstrate the development of an electronic health record (EHR)-tethered PHR app named MyHealthKeeper, which can retrieve data from a wearable device and deliver these data to a hospital EHR system, and (2) to study the effectiveness of a PHR data-driven clinical intervention with clinical trial results. To improve the conventional EHR-tethered PHR, we ascertained clinicians' unmet needs regarding PHR functionality and the data frequently used in the field through a cocreation workshop. We incorporated the requirements into the system design and architecture of the MyHealthKeeper PHR module. We constructed the app and validated the effectiveness of the PHR module by conducting a 4-week clinical trial. We used a commercially available activity tracker (Misfit) to collect individual physical activity data, and developed the MyHealthKeeper mobile phone app to record participants' patterns of daily food intake and activity logs. We randomly assigned 80 participants to either the PHR-based intervention group (n=51) or the control group (n=29). All of the study participants completed a paper-based survey, a laboratory test, a physical examination, and an opinion interview. During the 4-week study period, we collected health-related mobile data, and study participants visited the outpatient clinic twice and received PHR-based clinical diagnosis and recommendations. A total of 68 participants (44 in the intervention group and 24 in the control group) completed the study. The PHR intervention group showed significantly higher weight loss than the control group (mean 1.4 kg, 95% CI 0.9-1.9; P<.001) at the final week (week 4). In addition, triglyceride levels were significantly lower by the end of the study period (mean 2.59 mmol/L, 95% CI 17.6-75.8; P=.002). We developed an innovative EHR-tethered PHR system that allowed clinicians and patients to share lifelog data. This study shows the effectiveness of a patient-managed and clinician-guided health tracker system and its potential to improve patient clinical profiles. ClinicalTrials.gov NCT03200119; https://clinicaltrials.gov/ct2/show/NCT03200119 (Archived by WebCite at http://www.webcitation.org/6v01HaCdd). ©Borim Ryu, Nari Kim, Eunyoung Heo, Sooyoung Yoo, Keehyuck Lee, Hee Hwang, Jeong-Whun Kim, Yoojung Kim, Joongseek Lee, Se Young Jung. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.12.2017.

Comparison of three scoring systems in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding: a prospective observational study.

PubMed

Zhong, Min; Chen, Wan Jun; Lu, Xiao Ye; Qian, Jie; Zhu, Chang Qing

2016-12-01

To compare the performances of the Glasgow-Blatchford score (GBS), modified GBS (mGBS) and AIMS65 in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding (AUGIB). This study enrolled 320 consecutive patients with AUGIB. Patients at high and low risks of developing adverse clinical outcomes (rebleeding, the need of clinical intervention and death) were categorized according to the GBS, mGBS and AIMS65 scoring systems. The outcome of the patients were the occurrences of adverse clinical outcomes. The areas under the receiver operating characteristics curve (AUROC) of three scoring systems were compared. Irrespective of the systems used, the high-risk groups showed higher rates of rebleeding, intervention and death compared with the low-risk groups (P < 0.05). For the prediction of rebleeding, AIMS65 (AUROC 0.735, 95% CI 0.667-0.802) performed significantly better than GBS (AUROC 0.672, 95% CI 0.597-0.747; P < 0.01) and mGBS (AUROC 0.677, 95% CI 0.602-0.753; P < 0.01). For the prediction of interventions, there was no significant difference among the three systems (GBS: AUROC 0.769, 95% CI 0.668-0.870; mGBS: AUROC 0.745, 95% CI 0.643-0.847; AIMS65: AUROC 0.746, 95% CI 0.640-0.851). For the prediction of in-hospital mortality, there was no significant difference among the three systems (GBS: AUROC 0.796, 95% CI 0.694-0.898; mGBS: AUROC 0.803, 95% CI 0.703-0.904; AIMS65: AUROC 0.786, 95% CI 0.670-0.903). The three scoring systems are reliable and accurate in predicting the rates of rebleeding, surgery and mortality in AUGIB. However, AIMS65 outperforms GBS and mGBS in predicting rebleeding. © 2016 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.

Insights on Localized and Systemic Delivery of Redox-Based Therapeutics

PubMed Central

Batrakova, Elena V.; Mota, Roberto

2018-01-01

Reactive oxygen and nitrogen species are indispensable in cellular physiology and signaling. Overproduction of these reactive species or failure to maintain their levels within the physiological range results in cellular redox dysfunction, often termed cellular oxidative stress. Redox dysfunction in turn is at the molecular basis of disease etiology and progression. Accordingly, antioxidant intervention to restore redox homeostasis has been pursued as a therapeutic strategy for cardiovascular disease, cancer, and neurodegenerative disorders among many others. Despite preliminary success in cellular and animal models, redox-based interventions have virtually been ineffective in clinical trials. We propose the fundamental reason for their failure is a flawed delivery approach. Namely, systemic delivery for a geographically local disease limits the effectiveness of the antioxidant. We take a critical look at the literature and evaluate successful and unsuccessful approaches to translation of redox intervention to the clinical arena, including dose, patient selection, and delivery approach. We argue that when interpreting a failed antioxidant-based clinical trial, it is crucial to take into account these variables and importantly, whether the drug had an effect on the redox status. Finally, we propose that local and targeted delivery hold promise to translate redox-based therapies from the bench to the bedside. PMID:29636836

Increasing consumer demand for tobacco treatments: Ten design recommendations for clinicians and healthcare systems.

PubMed

Woods, Susan Swartz; Jaén, Carlos Roberto

2010-03-01

Health professionals play an important role in addressing patient tobacco use in clinical settings. While there is clear evidence that identifying tobacco use and assisting smokers in quitting affects outcomes, challenges to improve routine, clinician-delivered tobacco intervention persist. The Consumer Demand Initiative has identified simple design principles to increase consumers' use of proven tobacco treatments. Applying these design strategies to activities across the healthcare system, we articulate ten recommendations that can be implemented in the context of most clinical systems where most clinicians work. The recommendations are: (1) reframe the definition of success, (2) portray proven treatments as the best care, (3) redesign the 5A's of tobacco intervention, (4) be ready to deliver the right treatment at the right time, (5) move tobacco from the social history to the problem list, (6) use words as therapy and language that makes sense, (7) fit tobacco treatment into clinical team workflows, (8) embed tobacco treatment into health information technology, (9) make every encounter an opportunity to intervene, and (10) end social disparities for tobacco users. Clinical systems need to change to improve tobacco treatment implementation. The consumer- and clinician-centered recommendations provide a roadmap that focuses on increasing clinician performance through greater understanding of the clinician's role in helping tobacco users, highlighting the value of evidence-based tobacco treatments, employing shared decision-making skills, and integrating routine tobacco treatment into clinical system routines. Published by Elsevier Inc.

White Paper: Interventional MRI: Current Status and Potential for Development Considering Economic Perspectives, Part 1: General Application.

PubMed

Barkhausen, Jörg; Kahn, Thomas; Krombach, Gabriele A; Kuhl, Christiane K; Lotz, Joachim; Maintz, David; Ricke, Jens; Schönberg, Stefan O; Vogl, Thomas J; Wacker, Frank K

2017-07-01

Background  MRI is attractive for the guiding and monitoring of interventional procedures due to its high intrinsic soft tissue contrast and the possibility to measure physiologic parameters like flow and cardiac function. Method  The current status of interventional MRI for the clinical routine was analyzed. Results  The effort needed for the development of MR-safe monitoring systems and instruments initially resulted in the application of interventional MRI only for procedures that could not be performed by other means. Accordingly, biopsy of lesions in the breast, which are not detectable by other modalities, has been performed under MRI guidance for decades. Currently, biopsies of the prostate under MRI guidance are established in a similar fashion. At many sites blind biopsy has already been replaced by MR-guided biopsy or at least by the fusion of MR images with ultrasound. Cardiovascular interventions are performed at several centers for ablation as a treatment for atrial fibrillation. Conclusion  Interventional MRI has been established in the clinical routine for a variety of indications. Broader application can be expected in the clinical routine in the future owing to the multiple advantages compared to other techniques. Key points   · Due to the significant technical effort, MR-guided interventions are only recommended in the long term for regions in which MRI either facilitates or greatly improves the intervention.. · Breast biopsy of otherwise undetectable target lesions has long been established in the clinical routine. Prostate biopsy is currently being introduced in the clinical routine for similar reasons. Other methods such as MR-guided focused ultrasound for the treatment of uterine fibroids or tumor ablation of metastases represent alternative methods and are offered in many places.. · Endovascular MR-guided interventions offer advantages for a number of indications and have already been clinically established for the treatment of children with congenital heart defects and for atrial ablation at individual centers. Greater application can be expected in the future.. Citation format · Barkhausen J, Kahn T, Krombach GA et al. White Paper: Interventional MRI: Current Status and Potential for Development Considering Economic Perspectives, Part 1: General Application. Fortschr Röntgenstr 2017; 189: 611 - 623. © Georg Thieme Verlag KG Stuttgart · New York.

Design and development of C-arm based cone-beam CT for image-guided interventions: initial results

NASA Astrophysics Data System (ADS)

Chen, Guang-Hong; Zambelli, Joseph; Nett, Brian E.; Supanich, Mark; Riddell, Cyril; Belanger, Barry; Mistretta, Charles A.

2006-03-01

X-ray cone-beam computed tomography (CBCT) is of importance in image-guided intervention (IGI) and image-guided radiation therapy (IGRT). In this paper, we present a cone-beam CT data acquisition system using a GE INNOVA 4100 (GE Healthcare Technologies, Waukesha, Wisconsin) clinical system. This new cone-beam data acquisition mode was developed for research purposes without interfering with any clinical function of the system. It provides us a basic imaging pipeline for more advanced cone-beam data acquisition methods. It also provides us a platform to study and overcome the limiting factors such as cone-beam artifacts and limiting low contrast resolution in current C-arm based cone-beam CT systems. A geometrical calibration method was developed to experimentally determine parameters of the scanning geometry to correct the image reconstruction for geometric non-idealities. Extensive phantom studies and some small animal studies have been conducted to evaluate the performance of our cone-beam CT data acquisition system.

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

PubMed

Pickering, Brian W; Hurley, Killian; Marsh, Brian

2009-11-01

To use a handover assessment tool for identifying patient information corruption and objectively evaluating interventions designed to reduce handover errors and improve medical decision making. The continuous monitoring, intervention, and evaluation of the patient in modern intensive care unit practice generates large quantities of information, the platform on which medical decisions are made. Information corruption, defined as errors of distortion/omission compared with the medical record, may result in medical judgment errors. Identifying these errors may lead to quality improvements in intensive care unit care delivery and safety. Handover assessment instrument development study divided into two phases by the introduction of a handover intervention. Closed, 17-bed, university-affiliated mixed surgical/medical intensive care unit. Senior and junior medical members of the intensive care unit team. Electronic handover page. Study subjects were asked to recall clinical information commonly discussed at handover on individual patients. The handover score measured the percentage of information correctly retained for each individual doctor-patient interaction. The clinical intention score, a subjective measure of medical judgment, was graded (1-5) by three blinded intensive care unit experts. A total of 137 interactions were scored. Median (interquartile range) handover scores for phases 1 and 2 were 79.07% (67.44-84.50) and 83.72% (76.16-88.37), respectively. Score variance was reduced by the handover intervention (p < .05). Increasing median handover scores, 68.60 to 83.72, were associated with increases in clinical intention scores from 1 to 5 (chi-square = 23.59, df = 4, p < .0001). When asked to recall clinical information discussed at handover, medical members of the intensive care unit team provide data that are significantly corrupted compared with the medical record. Low subjective clinical judgment scores are significant associated with low handover scores. The handover/clinical intention scores may, therefore, be useful screening tools for intensive care unit system vulnerability to medical error. Additionally, handover instruments can identify interventions that reduce system vulnerability to error and may be used to guide quality improvements in handover practice.

Identifying the domains of context important to implementation science: a study protocol.

PubMed

Squires, Janet E; Graham, Ian D; Hutchinson, Alison M; Michie, Susan; Francis, Jill J; Sales, Anne; Brehaut, Jamie; Curran, Janet; Ivers, Noah; Lavis, John; Linklater, Stefanie; Fenton, Shannon; Noseworthy, Thomas; Vine, Jocelyn; Grimshaw, Jeremy M

2015-09-28

There is growing recognition that "context" can and does modify the effects of implementation interventions aimed at increasing healthcare professionals' use of research evidence in clinical practice. However, conceptual clarity about what exactly comprises "context" is lacking. The purpose of this research program is to develop, refine, and validate a framework that identifies the key domains of context (and their features) that can facilitate or hinder (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. A multi-phased investigation of context using mixed methods will be conducted. The first phase is a concept analysis of context using the Walker and Avant method to distinguish between the defining and irrelevant attributes of context. This phase will result in a preliminary framework for context that identifies its important domains and their features according to the published literature. The second phase is a secondary analysis of qualitative data from 13 studies of interviews with 312 healthcare professionals on the perceived barriers and enablers to their application of research evidence in clinical practice. These data will be analyzed inductively using constant comparative analysis. For the third phase, we will conduct semi-structured interviews with key health system stakeholders and change agents to elicit their knowledge and beliefs about the contextual features that influence the effectiveness of implementation interventions and healthcare professionals' use of evidence in clinical practice. Results from all three phases will be synthesized using a triangulation protocol to refine the context framework drawn from the concept analysis. The framework will then be assessed for content validity using an iterative Delphi approach with international experts (researchers and health system stakeholders/change agents). This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term "context" for advancing implementation science, improving healthcare professionals' use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts.

Integrating an internet-mediated walking program into family medicine clinical practice: a pilot feasibility study.

PubMed

Goodrich, David E; Buis, Lorraine R; Janney, Adrienne W; Ditty, Megan D; Krause, Christine W; Zheng, Kai; Sen, Ananda; Strecher, Victor J; Hess, Michael L; Piette, John D; Richardson, Caroline R

2011-06-24

Regular participation in physical activity can prevent many chronic health conditions. Computerized self-management programs are effective clinical tools to support patient participation in physical activity. This pilot study sought to develop and evaluate an online interface for primary care providers to refer patients to an Internet-mediated walking program called Stepping Up to Health (SUH) and to monitor participant progress in the program. In Phase I of the study, we recruited six pairs of physicians and medical assistants from two family practice clinics to assist with the design of a clinical interface. During Phase II, providers used the developed interface to refer patients to a six-week pilot intervention. Provider perspectives were assessed regarding the feasibility of integrating the program into routine care. Assessment tools included quantitative and qualitative data gathered from semi-structured interviews, surveys, and online usage logs. In Phase I, 13 providers used SUH and participated in two interviews. Providers emphasized the need for alerts flagging patients who were not doing well and the ability to review participant progress. Additionally, providers asked for summary views of data across all enrolled clinic patients as well as advertising materials for intervention recruitment. In response to this input, an interface was developed containing three pages: 1) a recruitment page, 2) a summary page, and 3) a detailed patient page. In Phase II, providers used the interface to refer 139 patients to SUH and 37 (27%) enrolled in the intervention. Providers rarely used the interface to monitor enrolled patients. Barriers to regular use of the intervention included lack of integration with the medical record system, competing priorities, patient disinterest, and physician unease with exercise referrals. Intention-to-treat analyses showed that patients increased walking by an average of 1493 steps/day from pre- to post-intervention (t = (36) = 4.13, p < 0.01). Providers successfully referred patients using the SUH provider interface, but were less willing to monitor patient compliance in the program. Patients who completed the program significantly increased their step counts. Future research is needed to test the effectiveness of integrating SUH with clinical information systems over a longer evaluation period.

Caring letters for suicide prevention: implementation of a multi-site randomized clinical trial in the U.S. military and Veteran Affairs healthcare systems.

PubMed

Luxton, David D; Thomas, Elissa K; Chipps, Joan; Relova, Rona M; Brown, Daphne; McLay, Robert; Lee, Tina T; Nakama, Helenna; Smolenski, Derek J

2014-03-01

Caring letters is a suicide prevention intervention that entails the sending of brief messages that espouse caring concern to patients following discharge from treatment. First tested more than four decades ago, this intervention is one of the only interventions shown in a randomized controlled trial to reduce suicide mortality rates. Due to elevated suicide risk among patients following psychiatric hospitalization and the steady increase in suicide rates among the U.S. military personnel, it is imperative to test interventions that may help prevent suicide among high-risk military personnel and veterans. This paper describes the design, methods, study protocol, and regulatory implementation processes for a multi-site randomized controlled trial that aims to evaluate the effectiveness of a caring emails intervention for suicide prevention in the military and VA healthcare systems. The primary outcome is suicide mortality rates to be determined 24 months post-discharge from index hospital stay. Healthcare re-utilization rates will also be evaluated and comprehensive data will be collected regarding suicide risk factors. Recommendations for navigating the military and VA research regulatory processes and implementing a multi-site clinical trial at military and VA hospitals are discussed. Published by Elsevier Inc.

Predictors of Short- and Long-Term Attrition From the Parents as Agents of Change Randomized Controlled Trial for Managing Pediatric Obesity.

PubMed

Spence, Nicholas D; Newton, Amanda S; Keaschuk, Rachel A; Ambler, Kathryn A; Jetha, Mary M; Holt, Nicholas L; Rosychuk, Rhonda J; Spence, John C; Sharma, Arya M; Ball, Geoff D C

Attrition in pediatric weight management is a substantial problem. This study examined factors associated with short- and long-term attrition from a lifestyle and behavioral intervention for parents of children with overweight or obesity. Fifty-two families with children ages 6 to 12 years old and body mass index at or above the 85th percentile participated in a randomized controlled trial focused on parents, comparing parent-based cognitive behavioral therapy with parent-based psychoeducation for pediatric weight management. We examined program attrition using two clinical phases of the intervention: short-term and long-term attrition, modeled using the general linear model. Predictors included intervention type, child/parent weight status, sociodemographic factors, and health of the family system. Higher self-assessed health of the family system was associated with lower short-term attrition; higher percentage of intervention sessions attended by parents was associated with lower long-term attrition. Different variables were significant in our short- and long-term models. Attrition might best be conceptualized based on short- and long-term phases of clinical, parent-based interventions for pediatric weight management. Copyright © 2016 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

Do Online Information Retrieval Systems Help Experienced Clinicians Answer Clinical Questions?

PubMed Central

Westbrook, Johanna I.; Coiera, Enrico W.; Gosling, A. Sophie

2005-01-01

Objective: To assess the impact of clinicians' use of an online information retrieval system on their performance in answering clinical questions. Design: Pre-/post-intervention experimental design. Measurements: In a computer laboratory, 75 clinicians (26 hospital-based doctors, 18 family practitioners, and 31 clinical nurse consultants) provided 600 answers to eight clinical scenarios before and after the use of an online information retrieval system. We examined the proportion of correct answers pre- and post-intervention, direction of change in answers, and differences between professional groups. Results: System use resulted in a 21% improvement in clinicians' answers, from 29% (95% confidence interval [CI] 25.4–32.6) correct pre- to 50% (95% CI 46.0–54.0) post-system use. In 33% (95% CI 29.1–36.9) answers were changed from incorrect to correct. In 21% (95% CI 17.1–23.9) correct pre-test answers were supported by evidence found using the system, and in 7% (95% CI 4.9–9.1) correct pre-test answers were changed incorrectly. For 40% (35.4–43.6) of scenarios, incorrect pre-test answers were not rectified following system use. Despite significant differences in professional groups' pre-test scores [family practitioners: 41% (95% CI 33.0–49.0), hospital doctors: 35% (95% CI 28.5–41.2), and clinical nurse consultants: 17% (95% CI 12.3–21.7; χ2 = 29.0, df = 2, p < 0.01)], there was no difference in post-test scores. (χ2 = 2.6, df = 2, p = 0.73). Conclusions: The use of an online information retrieval system was associated with a significant improvement in the quality of answers provided by clinicians to typical clinical problems. In a small proportion of cases, use of the system produced errors. While there was variation in the performance of clinical groups when answering questions unaided, performance did not differ significantly following system use. Online information retrieval systems can be an effective tool in improving the accuracy of clinicians' answers to clinical questions. PMID:15684126

Audit filters for improving processes of care and clinical outcomes in trauma systems.

PubMed

Evans, Christopher; Howes, Daniel; Pickett, William; Dagnone, Luigi

2009-10-07

Traumatic injuries represent a considerable public health burden with significant personal and societal costs. The care of the severely injured patient in a trauma system progresses along a continuum that includes numerous interventions being provided by a multidisciplinary group of healthcare personnel. Despite the recent emphasis on quality of care in medicine, there has been little research to direct trauma clinicians and administrators on how optimally to monitor and improve upon the quality of care delivered within a trauma system. Audit filters are one mechanism for improving quality of care and are defined as specific clinical processes or outcomes of care that, when they occur, represent unfavorable deviations from an established norm and which prompt review and feedback. Although audit filters are widely utilized for performance improvement in trauma systems they have not been subjected to systematic review of their effectiveness. To determine the effectiveness of using audit filters for improving processes of care and clinical outcomes in trauma systems. Our search strategy included an electronic search of the Cochrane Injuries Group Specialized Register, the Cochrane EPOC Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 4), MEDLINE, PubMed, EMBASE, CINAHL, and ISI Web of Science: (SCI-EXPANDED and CPCI-S). We handsearched the Journal of Trauma, Injury, Annals of Emergency Medicine, Academic Emergency Medicine, and Injury Prevention. We searched two clinical trial registries: 1) The World Health Organization International Clinical Trials Registry Platform and, 2) Clinical Trials.gov. We also contacted content experts for further articles. The most recent electronic search was completed in December 2008 and the handsearch was completed up to February 2009. We searched for randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series studies that used audit filters as an intervention for improving processes of care, morbidity, or mortality for severely injured patients. Two authors independently screened the search results, applied inclusion criteria, and extracted data. There were no studies identified that met the inclusion criteria for this review. We were unable to identify any studies of sufficient methodological quality to draw conclusions regarding the effectiveness of audit filters as a performance improvement intervention in trauma systems. Future research using rigorous study designs should focus on the relative effectiveness of audit filters in comparison to alternative quality improvement strategies at improving processes of care, functional outcomes, and mortality for injured patients.

The Neurobiology of Intervention and Prevention in Early Adversity.

PubMed

Fisher, Philip A; Beauchamp, Kate G; Roos, Leslie E; Noll, Laura K; Flannery, Jessica; Delker, Brianna C

2016-01-01

Early adverse experiences are well understood to affect development and well-being, placing individuals at risk for negative physical and mental health outcomes. A growing literature documents the effects of adversity on developing neurobiological systems. Fewer studies have examined stress neurobiology to understand how to mitigate the effects of early adversity. This review summarizes the research on three neurobiological systems relevant to interventions for populations experiencing high levels of early adversity: the hypothalamic-adrenal-pituitary axis, the prefrontal cortex regions involved in executive functioning, and the system involved in threat detection and response, particularly the amygdala. Also discussed is the emerging field of epigenetics and related interventions to mitigate early adversity. Further emphasized is the need for intervention research to integrate knowledge about the neurobiological effects of prenatal stressors (e.g., drug use, alcohol exposure) and early adversity. The review concludes with a discussion of the implications of this research topic for clinical psychology practice and public policy.

Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets.

PubMed

Garland, Eric L

2014-06-01

Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics--drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.

Initial clinical experience with a quadrupole butterfly coil for spinal injection interventions in an open MRI system at 1.0 tesla.

PubMed

Jonczyk, Martin; Hamm, Bernd; Heinrich, Andreas; Thomas, Andreas; Rathke, Hendrik; Schnackenburg, Bernhard; Güttler, Felix; Teichgräber, Ulf K M; de Bucourt, Maximilian

2014-02-01

To report our initial clinical experience with a new magnetic resonance imaging (MRI) quadrupole coil that allows interventions in prone position. Fifteen patients (seven women, eight men; average age, 42.8 years) were treated in the same 1.0-Tesla Panorama High Field Open (HFO) MRI system (Panorama HFO) using a quadrupole butterfly coil (Bfly) and compared with 15 patients matched for sex, age, and MR intervention using the MultiPurposeL coil (MPL), performed in conventional lateral decubitus position (all, Philips Medical Systems, Best, The Netherlands). All interventions were performed with a near-real-time proton density turbo spin echo (PD TSE) sequence (time to repeat/time to echo/flip angle/acquisition time, 600 ms/10 ms/90°/3 s/image). Qualitative and quantitative image analyses were performed, including signal intensity, signal-to-noise and contrast-to-noise ratio (SNR, CNR), contrast, and full width at half maximum (FWHM) measurements. Contrast differed significantly between the needle and muscles (Bfly 0.27/MPL 0.17), as well as the needle and periradicular fat (0.13/0.24) during the intervention (both, p=0.029), as well as the CNR between muscles and the needle (10.61/5.23; p=0.010), although the FWHM values did not (2.4/2.2; p=0.754). The signal intensity of the needle in interventional imaging (1152.9/793.2; p=0.006) and the postinterventional SNR values of subcutaneous fat (15.3/28.6; p=0.007), muscles (6.6/11.8; p=0.011), and the CNR between these tissues (8.7/17.5; p=0.004) yielded significant differences. The new coil is a valid alternative for MR-guided interventions in an open MRI system at 1.0 tesla, especially if patients cannot (or prefer not to) be in a lateral decubitus position or if prone positioning yields better access to the target zone.

Comprehensive approach for hypertension control in low-income populations: rationale and study design for the hypertension control program in Argentina.

PubMed

Mills, Katherine T; Rubinstein, Adolfo; Irazola, Vilma; Chen, Jing; Beratarrechea, Andrea; Poggio, Rosana; Dolan, Jacquelyn; Augustovski, Federico; Shi, Lizheng; Krousel-Wood, Marie; Bazzano, Lydia A; He, Jiang

2014-08-01

Although the efficacy and effectiveness of lifestyle modifications and antihypertensive pharmaceutical treatment for the prevention and control of hypertension and concomitant cardiovascular disease have been demonstrated in randomized controlled trials, this scientific knowledge has not been fully applied in the general population, especially in low-income communities. This article summarizes interventions to improve hypertension management and describes the rationale and study design for a cluster randomized trial testing whether a comprehensive intervention program within a national public primary care system will improve hypertension control among uninsured hypertensive men and women and their families. We will recruit 1,890 adults from 18 clinics within a public primary care network in Argentina. Clinic patients with uncontrolled hypertension, their spouses and hypertensive family members will be enrolled. The comprehensive intervention program targets the primary care system through health care provider education, a home-based intervention among patients and their families (home delivery of antihypertensive medication, self-monitoring of blood pressure [BP], health education for medication adherence and lifestyle modification) conducted by community health workers and a mobile health intervention. The primary outcome is net change in systolic BP from baseline to month 18 between intervention and control groups among hypertensive study participants. The secondary outcomes are net change in diastolic BP, BP control and cost-effectiveness of the intervention. This study will generate urgently needed data on effective, practical and sustainable intervention programs aimed at controlling hypertension and concomitant cardiovascular disease in underserved populations in low- and middle-income countries.

Comprehensive Approach for Hypertension Control in Low-income Populations: Rationale and Study Design for the Hypertension Control Program in Argentina (HCPIA)

PubMed Central

Mills, Katherine T.; Rubinstein, Adolfo; Irazola, Vilma; Chen, Jing; Beratarrechea, Andrea; Poggio, Rosana; Dolan, Jacquelyn; Augustovski, Federico; Shi, Lizheng; Krousel-Wood, Marie; Bazzano, Lydia A.; He, Jiang

2014-01-01

Although the efficacy and effectiveness of lifestyle modifications and antihypertensive pharmaceutical treatment for the prevention and control of hypertension and concomitant cardiovascular disease have been demonstrated in randomized controlled trials, this scientific knowledge has not been fully applied in the general population, especially in low-income communities. This paper summarizes interventions to improve hypertension management and describes the rationale and study design for a cluster randomized trial testing whether a comprehensive intervention program within a national public primary care system will improve hypertension control among uninsured hypertensive men and women and their families. We will recruit 1,890 adults from 18 clinics within a public primary care network in Argentina. Clinic patients with uncontrolled hypertension, their spouses and hypertensive family members will be enrolled. The comprehensive intervention program targets the primary care system through health care provider education, a home-based intervention among patients and their families (home delivery of antihypertensive medication, self-monitoring of blood pressure, health education for medication adherence and lifestyle modification) conducted by community health workers, and a mobile health intervention. The primary outcome is net change in systolic blood pressure from baseline to month 18 between intervention and control groups among hypertensive study participants. The secondary outcomes are net change in diastolic blood pressure, blood pressure control, and cost-effectiveness of the intervention. This study will generate urgently needed data on effective, practical, and sustainable intervention programs aimed at controlling hypertension and concomitant cardiovascular disease in underserved populations in low- and middle-income countries. PMID:24978148

Patient-Centered Appointment Scheduling Using Agent-Based Simulation

PubMed Central

Turkcan, Ayten; Toscos, Tammy; Doebbeling, Brad N.

2014-01-01

Enhanced access and continuity are key components of patient-centered care. Existing studies show that several interventions such as providing same day appointments, walk-in services, after-hours care, and group appointments, have been used to redesign the healthcare systems for improved access to primary care. However, an intervention focusing on a single component of care delivery (i.e. improving access to acute care) might have a negative impact other components of the system (i.e. reduced continuity of care for chronic patients). Therefore, primary care clinics should consider implementing multiple interventions tailored for their patient population needs. We collected rapid ethnography and observations to better understand clinic workflow and key constraints. We then developed an agent-based simulation model that includes all access modalities (appointments, walk-ins, and after-hours access), incorporate resources and key constraints and determine the best appointment scheduling method that improves access and continuity of care. This paper demonstrates the value of simulation models to test a variety of alternative strategies to improve access to care through scheduling. PMID:25954423

A knowledge translation intervention to enhance clinical application of a virtual reality system in stroke rehabilitation.

PubMed

Levac, Danielle; Glegg, Stephanie M N; Sveistrup, Heidi; Colquhoun, Heather; Miller, Patricia A; Finestone, Hillel; DePaul, Vincent; Harris, Jocelyn E; Velikonja, Diana

2016-10-06

Despite increasing evidence for the effectiveness of virtual reality (VR)-based therapy in stroke rehabilitation, few knowledge translation (KT) resources exist to support clinical integration. KT interventions addressing known barriers and facilitators to VR use are required. When environmental barriers to VR integration are less amenable to change, KT interventions can target modifiable barriers related to therapist knowledge and skills. A multi-faceted KT intervention was designed and implemented to support physical and occupational therapists in two stroke rehabilitation units in acquiring proficiency with use of the Interactive Exercise Rehabilitation System (IREX; GestureTek). The KT intervention consisted of interactive e-learning modules, hands-on workshops and experiential practice. Evaluation included the Assessing Determinants of Prospective Take Up of Virtual Reality (ADOPT-VR) Instrument and self-report confidence ratings of knowledge and skills pre- and post-study. Usability of the IREX was measured with the System Usability Scale (SUS). A focus group gathered therapist experiences. Frequency of IREX use was recorded for 6 months post-study. Eleven therapists delivered a total of 107 sessions of VR-based therapy to 34 clients with stroke. On the ADOPT-VR, significant pre-post improvements in therapist perceived behavioral control (p = 0.003), self-efficacy (p = 0.005) and facilitating conditions (p =0.019) related to VR use were observed. Therapist intention to use VR did not change. Knowledge and skills improved significantly following e-learning completion (p = 0.001) and was sustained 6 months post-study. Below average perceived usability of the IREX (19 th percentile) was reported. Lack of time was the most frequently reported barrier to VR use. A decrease in frequency of perceived barriers to VR use was not significant (p = 0.159). Two therapists used the IREX sparingly in the 6 months following the study. Therapists reported that client motivation to engage with VR facilitated IREX use in practice but that environmental and IREX-specific barriers limited use. Despite increased knowledge and skills in VR use, the KT intervention did not alter the number of perceived barriers to VR use, intention to use or actual use of VR. Poor perceived system usability had an impact on integration of this particular VR system into clinical practice.

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

PubMed Central

Harris, Sion K.; Aalsma, Matthew C.; Weitzman, Elissa R.; Garcia-Huidobro, Diego; Wong, Charlene; Hadland, Scott E.; Santelli, John; Park, M. Jane; Ozer, Elizabeth M.

2017-01-01

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act’s provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology—such as gaming platforms, mobile phone applications, and wearable devices—suggests opportunities to expand clinicians’ reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care. PMID:28011064

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

PubMed

Harris, Sion K; Aalsma, Matthew C; Weitzman, Elissa R; Garcia-Huidobro, Diego; Wong, Charlene; Hadland, Scott E; Santelli, John; Park, M Jane; Ozer, Elizabeth M

2017-03-01

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Cost-effectiveness of an exercise intervention program in perimenopausal women: the Fitness League Against MENopause COst (FLAMENCO) randomized controlled trial.

PubMed

Carbonell-Baeza, Ana; Soriano-Maldonado, Alberto; Gallo, Francisco Javier; López del Amo, María Puerto; Ruiz-Cabello, Pilar; Andrade, Ana; Borges-Cosic, Milkana; Peces-Rama, Antonio Rubén; Spacírová, Zuzana; Álvarez-Gallardo, Inmaculada C; García-Mochón, Leticia; Segura-Jiménez, Víctor; Estévez-López, Fernando; Camiletti-Moirón, Daniel; Martín-Martín, Jose Jesús; Aranda, Pilar; Delgado-Fernández, Manuel; Aparicio, Virginia A

2015-06-17

The high prevalence of women that do not reach the recommended level of physical activity is worrisome. A sedentary lifestyle has negative consequences on health status and increases health care costs. The main objective of this project is to assess the cost-effectiveness of a primary care-based exercise intervention in perimenopausal women. The present study is a Randomized Controlled Trial. A total of 150 eligible women will be recruited and randomly assigned to either a 16-week exercise intervention (3 sessions/week), or to usual care (control) group. The primary outcome measure is the incremental cost-effectiveness ratio. The secondary outcome measures are: i) socio-demographic and clinical information; ii) body composition; iii) dietary patterns; iv) glycaemic and lipid profile; v) physical fitness; vi) physical activity and sedentary behaviour; vii) sleep quality; viii) quality of life, mental health and positive health; ix) menopause symptoms. All outcomes will be assessed at baseline and post intervention. The data will be analysed on an intention-to-treat basis and per protocol. In addition, we will conduct a cost effectiveness analysis from a health system perspective. The intervention designed is feasible and if it proves to be clinically and cost effective, it can be easily transferred to other similar contexts. Consequently, the findings of this project might help the Health Systems to identify strategies for primary prevention and health promotion as well as to reduce health care requirements and costs. ClinicalTrials.gov Identifier: NCT02358109. Date of registration: 05/02/2015.

Development, implementation, and evaluation of a hybrid electronic medical record system specifically designed for a developing world surgical service.

PubMed

Laing, G L; Bruce, J L; Skinner, D L; Allorto, N L; Clarke, D L; Aldous, C

2014-06-01

The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS). Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death). A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high. It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.

Review of systems, physical examination, and routine tests for case-finding in ambulatory patients.

PubMed

Boland, B J; Wollan, P C; Silverstein, M D

1995-04-01

The screening value of the comprehensive review of systems and the complete physical examination in detecting unsuspected diseases for which therapeutic interventions are initiated has not been formally studied in ambulatory patients. The medical records of 100 randomly selected adult patients who had an ambulatory general medical evaluation at the Mayo Clinic in 1990-1991 were surveyed to compare review of systems and physical examination with routine laboratory tests, chest radiography, and electrocardiography as case-finding maneuvers. The main outcome measure was the therapeutic yield of each case-finding maneuver, defined as the proportion of maneuvers leading to a new therapy for a new clinically important diagnosis. The utilization rate of routine tests in the 100 patients (mean age: 59 +/- 16 years; 58% women) was high, ranging from 77 to 98%. Overall, the case-finding maneuvers led to 36 unsuspected clinically important diagnoses and resulted in 25 new therapeutic interventions. Higher therapeutic yield was observed for review of systems (7%), physical examination (5%), and lipid screening (9.2%) than for chemistry group (2.2%), complete blood count (1.8%), thyroid tests (1.5%), urinalysis (1.1%), electrocardiography (0%), or chest radiography (0%). The number of therapeutic interventions was not associated with patient's age (P = 0.55), sex (P = 0.88), comorbidity (P = 0.30) or with the time interval since the last general medical evaluation (P = 0.12). Based on therapeutic yield, these data suggest that review of systems and physical examination are valuable case-finding maneuvers in the periodic medical evaluation of ambulatory patients.

Barriers and Promoters of an Evidenced-Based Smoking Cessation Counseling During Prenatal Care in Argentina and Uruguay

PubMed Central

Tong, Van T.; Morello, Paola; Farr, Sherry L.; Lawsin, Catalina; Dietz, Patricia M.; Aleman, Alicia; Berrueta, Mabel; Mazzoni, Agustina; Becu, Ana; Buekens, Pierre; Belizán, José; Althabe, Fernando

2015-01-01

In Argentina and Uruguay, 10.3 and 18.3 %, respectively, of pregnant women smoked in 2005. Brief cessation counseling, based on the 5A’s model, has been effective in different settings. This qualitative study aims to improve the understanding of factors influencing the provision of smoking cessation counseling during pregnancy in Argentina and Uruguay. In 2010, we obtained prenatal care providers’, clinic directors’, and pregnant smokers’ opinions regarding barriers and promoters to brief smoking cessation counseling in publicly-funded prenatal care clinics in Buenos Aires, Argentina and Montevideo, Uruguay. We interviewed six prenatal clinic directors, conducted focus groups with 46 health professionals and 24 pregnant smokers. Themes emerged from three issue areas: health professionals, health system, and patients. Health professional barriers to cessation counseling included inadequate knowledge and motivation, perceived low self-efficacy, and concerns about inadequate time and large workload. They expressed interest in obtaining a counseling script. Health system barriers included low prioritization of smoking cessation and a lack of clinic protocols to implement interventions. Pregnant smokers lacked information on the risks of prenatal smoking and underestimated the difficulty of smoking cessation. Having access to written materials and receiving cessation services during clinic waiting times were mentioned as promoters for the intervention. Women also were receptive to non-physician office staff delivering intervention components. Implementing smoking cessation counseling in publicly-funded prenatal care clinics in Argentina and Uruguay may require integrating counseling into routine prenatal care and educating and training providers on best-practices approaches. PMID:25500989

Can the theoretical domains framework account for the implementation of clinical quality interventions?

PubMed

Lipworth, Wendy; Taylor, Natalie; Braithwaite, Jeffrey

2013-12-21

The health care quality improvement movement is a complex enterprise. Implementing clinical quality initiatives requires attitude and behaviour change on the part of clinicians, but this has proven to be difficult. In an attempt to solve this kind of behavioural challenge, the theoretical domains framework (TDF) has been developed. The TDF consists of 14 domains from psychological and organisational theory said to influence behaviour change. No systematic research has been conducted into the ways in which clinical quality initiatives map on to the domains of the framework. We therefore conducted a qualitative mapping experiment to determine to what extent, and in what ways, the TDF is relevant to the implementation of clinical quality interventions. We conducted a thematic synthesis of the qualitative literature exploring clinicians' perceptions of various clinical quality interventions. We analysed and synthesised 50 studies in total, in five domains of clinical quality interventions: clinical quality interventions in general, structural interventions, audit-type interventions, interventions aimed at making practice more evidence-based, and risk management interventions. Data were analysed thematically, followed by synthesis of these themes into categories and concepts, which were then mapped to the domains of the TDF. Our results suggest that the TDF is highly relevant to the implementation of clinical quality interventions. It can be used to map most, if not all, of the attitudinal and behavioural barriers and facilitators of uptake of clinical quality interventions. Each of these 14 domains appeared to be relevant to many different types of clinical quality interventions. One possible additional domain might relate to perceived trustworthiness of those instituting clinical quality interventions. The TDF can be usefully applied to a wide range of clinical quality interventions. Because all 14 of the domains emerged as relevant, and we did not identify any obvious differences between different kinds of clinical quality interventions, our findings support an initially broad approach to identifying barriers and facilitators, followed by a "drilling down" to what is most contextually salient. In future, it may be possible to establish a model of clinical quality policy implementation using the TDF.

Can the theoretical domains framework account for the implementation of clinical quality interventions?

PubMed Central

2013-01-01

Background The health care quality improvement movement is a complex enterprise. Implementing clinical quality initiatives requires attitude and behaviour change on the part of clinicians, but this has proven to be difficult. In an attempt to solve this kind of behavioural challenge, the theoretical domains framework (TDF) has been developed. The TDF consists of 14 domains from psychological and organisational theory said to influence behaviour change. No systematic research has been conducted into the ways in which clinical quality initiatives map on to the domains of the framework. We therefore conducted a qualitative mapping experiment to determine to what extent, and in what ways, the TDF is relevant to the implementation of clinical quality interventions. Methods We conducted a thematic synthesis of the qualitative literature exploring clinicians’ perceptions of various clinical quality interventions. We analysed and synthesised 50 studies in total, in five domains of clinical quality interventions: clinical quality interventions in general, structural interventions, audit-type interventions, interventions aimed at making practice more evidence-based, and risk management interventions. Data were analysed thematically, followed by synthesis of these themes into categories and concepts, which were then mapped to the domains of the TDF. Results Our results suggest that the TDF is highly relevant to the implementation of clinical quality interventions. It can be used to map most, if not all, of the attitudinal and behavioural barriers and facilitators of uptake of clinical quality interventions. Each of these 14 domains appeared to be relevant to many different types of clinical quality interventions. One possible additional domain might relate to perceived trustworthiness of those instituting clinical quality interventions. Conclusions The TDF can be usefully applied to a wide range of clinical quality interventions. Because all 14 of the domains emerged as relevant, and we did not identify any obvious differences between different kinds of clinical quality interventions, our findings support an initially broad approach to identifying barriers and facilitators, followed by a “drilling down” to what is most contextually salient. In future, it may be possible to establish a model of clinical quality policy implementation using the TDF. PMID:24359085

Early intervention for substance abuse among youth and young adults with mental health conditions: an exploration of community mental health practices.

PubMed

Anthony, Elizabeth K; Taylor, Sarah A; Raffo, Zulma

2011-05-01

This mixed method study examined current practices and barriers for screening and assessing substance use among youth/young adults in community mental health systems. Substance use rates remain high among youth/young adults in the general population and substance use disorders are prevalent among young people involved in public service systems such as mental health. In an effort to understand the dynamics for early intervention, 64 case managers and/or clinical directors from children's mental health systems in two states participated in an online survey or focus group in fall 2008. Quantitative survey questions and qualitative focus group questions explored attitudes and perspectives about screening and early intervention for substance use among youth/young adults involved in the mental health system and current agency practices. Mixed method results suggest a number of barriers to substance use screening and early intervention and point to innovations that could be more effectively supported.

Patients at the Centre: Methodological Considerations for Evaluating Evidence from Health Interventions Involving Patients Use of Web-Based Information Systems

PubMed Central

Cummings, Elizabeth; Turner, Paul

2010-01-01

Building an evidence base for healthcare interventions has long been advocated as both professionally and ethically desirable. By supporting meaningful comparison amongst different approaches, a good evidence base has been viewed as an important element in optimising clinical decision-making and the safety and quality of care. Unsurprisingly, medical research has put considerable effort into supporting the development of this evidence base, and the randomised controlled trial has become the dominant methodology. Recently however, a body of research has begun to question, not just this methodology per se, but also the extent to which the evidence it produces may marginalise individual patient experiences, priorities and perceptions. Simultaneously, the widespread adoption and utilisation of information systems (IS) in health care has also prompted initiatives to develop a stronger base of evidence about their impacts. These calls have been stimulated both by numerous system failures and research expressing concerns about the limitations of information systems methodologies in health care environments. Alongside the potential of information systems to produce positive, negative and unintended consequences, many measures of success, impact or benefit appear to have little to do with improvements in care, health outcomes or individual patient experiences. Combined these methodological concerns suggest the need for more detailed examination. This is particularly the case, given the prevalence within contemporary clinical and IS discourses on health interventions advocating the need to put the ‘patient at the centre’ by engaging them in their own care and/or ‘empowering’ them through the use of information systems. This paper aims to contribute to these on-going debates by focusing on the socio-technical processes by which patients’ interests and outcomes are measured, defined and evaluated within health interventions that involve them using web-based information systems. The paper outlines an integrated approach that aims to generate evidence about the impact of these types of health interventions that are meaningful at both individual patient and patient cohort levels. PMID:21594007

Strengthening the afferent limb of rapid response systems: an educational intervention using web-based learning for early recognition and responding to deteriorating patients.

PubMed

Liaw, Sok Ying; Wong, Lai Fun; Ang, Sophia Bee Leng; Ho, Jasmine Tze Yin; Siau, Chiang; Ang, Emily Neo Kim

2016-06-01

The timely recognition and response to patients with clinical deteriorations constitute the afferent limb failure of a rapid response system (RRS). This area is a persistent problem in acute healthcare settings worldwide. In this study, we evaluated the effect of an educational programme on improving the nurses' knowledge and performances in recognising and responding to clinical deterioration. The interactive web-based programme addressed three areas: (1) early detection of changes in vital signs; (2) performance of nursing assessment and interventions using airway, breathing, circulation, disability and expose/examine and (3) reporting clinical deterioration using identity, situation, background, assessment and recommendation. Sixty-seven registered nurses participated in the randomised control study. The experimental group underwent a 3 h programme while the control group received no intervention. Pretests and post-tests, a mannequin-based assessment and a multiple-choice knowledge questionnaire were conducted. We evaluated the participants' performances in assessing, managing and reporting the deterioration of a patient using a validated performance tool. A significantly higher number of nurses from the experimental group than the control group monitored respiratory rates (48.2% vs 25%, p<0.05) and pulse rates (74.3% vs 37.5%, p<0.01) in the simulated environment, after the intervention. The post-test mean scores of the experimental group was significantly higher than the control group for knowledge (21.29 vs 18.28, p<0.001), performance in assessing and managing clinical deterioration (25.83 vs 19.50, p<0.001) and reporting clinical deterioration (12.83 vs 10.97, p<0.001). A web-based educational programme developed for hospital nurses to strengthen the afferent limb of the RRS significantly increased their knowledge and performances in assessing, managing and reporting clinical deterioration. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Clinical Decision Support for a Multicenter Trial of Pediatric Head Trauma

PubMed Central

Swietlik, Marguerite; Deakyne, Sara; Hoffman, Jeffrey M.; Grundmeier, Robert W.; Paterno, Marilyn D.; Rocha, Beatriz H.; Schaeffer, Molly H; Pabbathi, Deepika; Alessandrini, Evaline; Ballard, Dustin; Goldberg, Howard S.; Kuppermann, Nathan; Dayan, Peter S.

2016-01-01

Summary Introduction For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial. Methods Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic® EHR. All sites implementing EHR-based CDS built the rules by using the vendor’s CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations. Results The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed. Conclusions The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial. PMID:27437059

Effectiveness of the VOICES/VOCES sexually transmitted disease/human immunodeficiency virus prevention intervention when administered by health department staff: does it work in the "real world"?

PubMed

Neumann, Mary Spink; O'Donnell, Lydia; Doval, Alexi San; Schillinger, Julia; Blank, Susan; Ortiz-Rios, Elizabeth; Garcia, Trinidad; O'Donnell, Carl R

2011-02-01

Prevention providers wonder whether benefits achieved in the original, researcher-led, efficacy trials of interventions are replicated when the intervention is delivered in real-world settings by their agency's staff. A replication study was conducted at 2 public sexually transmitted disease (STD) clinics (New York City and San Juan, PR). Using a controlled trial design, intervention (VOICES/VOCES) and comparison conditions (regular clinic services) were assigned in alternating 4-week blocks. Trained agency staff delivered the intervention. Effectiveness was assessed for incident STDs, redemption of coupons for condoms at neighborhood location after the visit, and improved knowledge and attitudes about STDs and condoms. A total of 3365 patients were recruited, completed the protocol, and followed through STD surveillance systems for an average of 17 months. Of 397 with an incident infection, 226 (13.4%) were among those enrolled during comparison blocks; 171 were among those in the intervention condition (10.2%). Controlling for site and gender, participants enrolled during intervention blocks were significantly less likely to have an incident STD reported to the surveillance system (hazard ratio, 0.78; 95% confidence interval, 0.64-0.96). Intervention block participants scored higher on scales of STD knowledge (4.89 vs. 3.87, P < 0.001) and condom knowledge, attitude, and efficacy (10.98 vs. 9.16, P < 0.001). More of those exposed to VOICES/VOCES redeemed condoms (P < 0.05). Positive effects were more consistent in New York, which may be related to fidelity of implementation. A packaged human immunodeficiency virus prevention intervention can be delivered by agencies, with benefits similar to those achieved in the research setting.

Impact of amyloid-beta changes on cognitive outcomes in Alzheimer's disease: analysis of clinical trials using a quantitative systems pharmacology model.

PubMed

Geerts, Hugo; Spiros, Athan; Roberts, Patrick

2018-02-02

Despite a tremendous amount of information on the role of amyloid in Alzheimer's disease (AD), almost all clinical trials testing this hypothesis have failed to generate clinically relevant cognitive effects. We present an advanced mechanism-based and biophysically realistic quantitative systems pharmacology computer model of an Alzheimer-type neuronal cortical network that has been calibrated with Alzheimer Disease Assessment Scale, cognitive subscale (ADAS-Cog) readouts from historical clinical trials and simulated the differential impact of amyloid-beta (Aβ40 and Aβ42) oligomers on glutamate and nicotinic neurotransmission. Preclinical data suggest a beneficial effect of shorter Aβ forms within a limited dose range. Such a beneficial effect of Aβ40 on glutamate neurotransmission in human patients is absolutely necessary to reproduce clinical data on the ADAS-Cog in minimal cognitive impairment (MCI) patients with and without amyloid load, the effect of APOE genotype effect on the slope of the cognitive trajectory over time in placebo AD patients and higher sensitivity to cholinergic manipulation with scopolamine associated with higher Aβ in MCI subjects. We further derive a relationship between units of Aβ load in our model and the standard uptake value ratio from amyloid imaging. When introducing the documented clinical pharmacodynamic effects on Aβ levels for various amyloid-related clinical interventions in patients with low Aβ baseline, the platform predicts an overall significant worsening for passive vaccination with solanezumab, beta-secretase inhibitor verubecestat and gamma-secretase inhibitor semagacestat. In contrast, all three interventions improved cognition in subjects with moderate to high baseline Aβ levels, with verubecestat anticipated to have the greatest effect (around ADAS-Cog value 1.5 points), solanezumab the lowest (0.8 ADAS-Cog value points) and semagacestat in between. This could explain the success of many amyloid interventions in transgene animals with an artificial high level of Aβ, but not in AD patients with a large variability of amyloid loads. If these predictions are confirmed in post-hoc analyses of failed clinical amyloid-modulating trials, one should question the rationale behind testing these interventions in early and prodromal subjects with low or zero amyloid load.

Costs Associated with Implementation of Computer-Assisted Clinical Decision Support System for Antenatal and Delivery Care: Case Study of Kassena-Nankana District of Northern Ghana

PubMed Central

Dalaba, Maxwell Ayindenaba; Akweongo, Patricia; Williams, John; Saronga, Happiness Pius; Tonchev, Pencho; Sauerborn, Rainer; Mensah, Nathan; Blank, Antje; Kaltschmidt, Jens; Loukanova, Svetla

2014-01-01

Objective This study analyzed cost of implementing computer-assisted Clinical Decision Support System (CDSS) in selected health care centres in Ghana. Methods A descriptive cross sectional study was conducted in the Kassena-Nankana district (KND). CDSS was deployed in selected health centres in KND as an intervention to manage patients attending antenatal clinics and the labour ward. The CDSS users were mainly nurses who were trained. Activities and associated costs involved in the implementation of CDSS (pre-intervention and intervention) were collected for the period between 2009–2013 from the provider perspective. The ingredients approach was used for the cost analysis. Costs were grouped into personnel, trainings, overheads (recurrent costs) and equipment costs (capital cost). We calculated cost without annualizing capital cost to represent financial cost and cost with annualizing capital costs to represent economic cost. Results Twenty-two trained CDSS users (at least 2 users per health centre) participated in the study. Between April 2012 and March 2013, users managed 5,595 antenatal clients and 872 labour clients using the CDSS. We observed a decrease in the proportion of complications during delivery (pre-intervention 10.74% versus post-intervention 9.64%) and a reduction in the number of maternal deaths (pre-intervention 4 deaths versus post-intervention 1 death). The overall financial cost of CDSS implementation was US$23,316, approximately US$1,060 per CDSS user trained. Of the total cost of implementation, 48% (US$11,272) was pre-intervention cost and intervention cost was 52% (US$12,044). Equipment costs accounted for the largest proportion of financial cost: 34% (US$7,917). When economic cost was considered, total cost of implementation was US$17,128–lower than the financial cost by 26.5%. Conclusions The study provides useful information in the implementation of CDSS at health facilities to enhance health workers' adherence to practice guidelines and taking accurate decisions to improve maternal health care. PMID:25180831

Guided Internet-based versus face-to-face clinical care in the management of tinnitus: study protocol for a multi-centre randomised controlled trial.

PubMed

Beukes, Eldré W; Baguley, David M; Allen, Peter M; Manchaiah, Vinaya; Andersson, Gerhard

2017-04-21

Innovative strategies are required to improve access to evidence-based tinnitus interventions. A guided Internet-based cognitive behavioural therapy (iCBT) intervention for tinnitus was therefore developed for a U.K. Initial clinical trials indicated efficacy of iCBT at reducing tinnitus severity and associated comorbidities such as insomnia and depression. The aim of this phase III randomised controlled trial is to compare this new iCBT intervention with an established intervention, namely face-to-face clinical care for tinnitus. This will be a multi-centre study undertaken across three hospitals in the East of England. The design is a randomised, two-arm, parallel-group, non-inferiority trial with a 2-month follow-up. The experimental group will receive the guided iCBT intervention, whereas the active control group will receive the usual face-to-face clinical care. An independent researcher will randomly assign participants, using a computer-generated randomisation schedule, after stratification for tinnitus severity. There will be 46 participants in each group. The primary assessment measure will be the Tinnitus Functional Index. Data analysis will establish whether non-inferiority is achieved using a pre-defined non-inferiority margin. This protocol outlines phase III of a clinical trial comparing a new iCBT with established face-to-face care for tinnitus. If guided iCBT for tinnitus proves to be as effective as the usual tinnitus care, it may be a viable additional management route for individuals with tinnitus. This could increase access to evidence-based effective tinnitus care and reduce the pressures on existing health care systems. ClinicalTrials.gov identifier: NCT02665975 . Registered on 22 January 2016.

Recent Internet Use and Associations with Clinical Outcomes among Patients Entering Addiction Treatment Involved in a Web-Delivered Psychosocial Intervention Study.

PubMed

Tofighi, B; Campbell, A N C; Pavlicova, M; Hu, M C; Lee, J D; Nunes, E V

2016-10-01

The acceptability and clinical impact of a web-based intervention among patients entering addiction treatment who lack recent internet access are unclear. This secondary analysis of a national multisite treatment study (NIDA Clinical Trials Network-0044) assessed for acceptability and clinical impact of a web-based psychosocial intervention among participants enrolling in community-based, outpatient addiction treatment programs. Participants were randomly assigned to 12 weeks of a web-based therapeutic education system (TES) based on the community reinforcement approach plus contingency management versus treatment as usual (TAU). Demographic and clinical characteristics, and treatment outcomes were compared among participants with recent internet access in the 90 days preceding enrollment (N = 374) and without internet access (N = 133). Primary outcome variables included (1) acceptability of TES (i.e., module completion; acceptability of web-based intervention) and (2) clinical impact (i.e., self-reported abstinence confirmed by urine drug/breath alcohol tests; retention measured as time to dropout). Internet use was common (74 %) and was more likely among younger (18-49 years old) participants and those who completed high school (p < .001). Participants randomized to TES (n = 255) without baseline internet access rated the acceptability of TES modules significantly higher than those with internet access (t = 2.49, df = 218, p = .01). There was a near significant interaction between treatment, baseline abstinence, and internet access on time to dropout (χ 2 (1) = 3.8089, p = .051). TES was associated with better retention among participants not abstinent at baseline who had internet access (X 2 (1) = 6.69, p = .01). These findings demonstrate high acceptability of this web-based intervention among participants that lacked recent internet access.

A Three-Phase Decision Model of Computer-Aided Coding for the Iranian Classification of Health Interventions (IRCHI).

PubMed

Azadmanjir, Zahra; Safdari, Reza; Ghazisaeedi, Marjan; Mokhtaran, Mehrshad; Kameli, Mohammad Esmail

2017-06-01

Accurate coded data in the healthcare are critical. Computer-Assisted Coding (CAC) is an effective tool to improve clinical coding in particular when a new classification will be developed and implemented. But determine the appropriate method for development need to consider the specifications of existing CAC systems, requirements for each type, our infrastructure and also, the classification scheme. The aim of the study was the development of a decision model for determining accurate code of each medical intervention in Iranian Classification of Health Interventions (IRCHI) that can be implemented as a suitable CAC system. first, a sample of existing CAC systems was reviewed. Then feasibility of each one of CAC types was examined with regard to their prerequisites for their implementation. The next step, proper model was proposed according to the structure of the classification scheme and was implemented as an interactive system. There is a significant relationship between the level of assistance of a CAC system and integration of it with electronic medical documents. Implementation of fully automated CAC systems is impossible due to immature development of electronic medical record and problems in using language for medical documenting. So, a model was proposed to develop semi-automated CAC system based on hierarchical relationships between entities in the classification scheme and also the logic of decision making to specify the characters of code step by step through a web-based interactive user interface for CAC. It was composed of three phases to select Target, Action and Means respectively for an intervention. The proposed model was suitable the current status of clinical documentation and coding in Iran and also, the structure of new classification scheme. Our results show it was practical. However, the model needs to be evaluated in the next stage of the research.

Successful Outcomes of a Clinical Decision Support System in an HIV Practice: A Randomized Controlled Trial

PubMed Central

Robbins, Gregory K.; Lester, William; Johnson, Kristin L.; Chang, Yuchiao; Estey, Gregory; Surrao, Dominic; Zachary, Kimon; Lammert, Sara M.; Chueh, Henry; Meigs, James B.; Freedberg, Kenneth A.

2013-01-01

Background Data to support improved patient outcomes from clinical decision support systems (CDSS) are lacking in HIV care. Objective To conduct a randomized controlled trial testing the efficacy of a CDSS to improve HIV outcomes in an outpatient clinic. Design We conducted a randomized controlled trial where half of each provider’s patients were randomized to interactive or static computer alerts (ClinicalTrials.gov #NCT00678600). Setting The study was conducted at the Massachusetts General Hospital HIV Clinic. Subjects Participants were HIV providers and their HIV-infected patients. Intervention Computer alerts were generated for virologic failure (HIV RNA >400 c/mL after HIV RNA ≤400 c/mL), evidence of suboptimal follow-up, and 11 abnormal laboratory tests. Providers received interactive computer alerts, facilitating appointment rescheduling and repeat laboratory testing, for half of their patients and static alerts for the other half. Measurements The primary endpoint was change in CD4 count. Other endpoints included time-to-clinical event, 6-month suboptimal follow-up, and severe laboratory toxicity. Results Thirty-three HIV providers followed 1,011 HIV-infected patients. For the intervention arm, the mean CD4 count increase was greater (5.3 versus 3.2 cells/mm3/month; difference = 2.0 cells/mm3/month 95% CI [0.1, 4.0], p=0.040) and the rate of 6-month suboptimal follow-up was lower (20.6 versus 30.1 events per 100 patient-years, p=0.022). Median time-to-next scheduled appointment was shorter in the intervention arm after a suboptimal follow-up alert (1.71 versus 3.48 months; p<0.001) and after a toxicity alert (2.79 versus >6 months for control); p=0.072). Ninety-six percent of providers supported adopting the CDSS as part of standard care. Limitations This was a one-year informatics study conducted at a single hospital sub-specialty clinic. Conclusion A CDSS using interactive provider alerts improved CD4 counts and clinic follow-up for HIV-infected patients. Wider implementation of such systems can provide important clinical benefits. PMID:23208165

e_Disease Management. A system for the management of the chronic conditions.

PubMed

Guillén, Sergio; Meneu, Maria Teresa; Serafin, Riccardo; Arredondo, Maria Teresa; Castellano, Elena; Valdivieso, Bernardo

2010-01-01

Disease Management (DM) is a system of coordinated healthcare intervention and communications for populations with conditions in which patient self-care efforts are significant. e-DM makes reference to processes of DM based on clinical guidelines sustained in the scientific medical evidence and supported by the intervention of Information and Telecommunication Technology (ICT) in all levels where these plans are developed. This paper discusses the design and implementation of a e-DM system which meets the requirements for the integrated chronic disease management following the recommendations of the Disease Management Association and the American Heart Association.

Effectiveness of a clinical practice change intervention in increasing the provision of nicotine dependence treatment in inpatient psychiatric facilities: an implementation trial.

PubMed

Wye, Paula M; Stockings, Emily A; Bowman, Jenny A; Oldmeadow, Chris; Wiggers, John H

2017-02-07

Despite clinical practice guidelines recommending the routine provision of nicotine dependence treatment to smokers in inpatient psychiatric facilities, the prevalence of such treatment provision is low. The aim of this study was to examine the effectiveness of a clinical practice change intervention in increasing clinician recorded provision of nicotine dependence treatment to patients in inpatient psychiatric facilities. We undertook an interrupted time series analysis of nicotine dependence treatment provision before, during and after a clinical practice change intervention to increase clinician recorded provision of nicotine dependence treatment for all hospital discharges (aged >18 years, N = 4175) over a 19 month period in two inpatient adult psychiatric facilities in New South Wales, Australia. The clinical practice change intervention comprised six key strategies: leadership and consensus, enabling systems and procedures, training and education, information and resources, audit and feedback and an on-site practice change support officer. Systematic medical record audit and segmented logistic regression was used to determine differences in proportions for each nicotine dependence treatment outcome measure between the 'pre', 'during' and 'post-intervention' periods. The prevalence of all five outcome measures increased significantly between the pre and post-intervention periods, including clinician recorded: assessment of patient smoking status (36.43 to 51.95%; adjusted odds ratio [AOR] = 2.39, 99% Confidence Interval [CI]: 1.23 to 4.66); assessment of patient nicotine dependence status (4.74 to 11.04%; AOR = 109.67, 99% CI: 35.35 to 340.22); provision of brief advice to quit (0.85 to 8.81%; AOR = 97.43, 99% CI: 31.03 to 306.30); provision of nicotine replacement therapy (8.06 to 26.25%; AOR = 19.59, 99% CI: 8.17 to 46.94); and provision of nicotine dependence treatment on discharge (8.82 to 13.45%, AOR = 12.36; 99% CI: 6.08 to 25.14). This is the first study to provide evidence that a clinical practice change intervention may increase clinician recorded provision of nicotine dependence treatment in inpatient psychiatric settings. The intervention offers a mechanism for psychiatric facilities to increase the provision of nicotine dependence treatment in accordance with clinical guidelines.

Clinical Impact Research – how to choose experimental or observational intervention study?

PubMed Central

Malmivaara, Antti

2016-01-01

Abstract Background: Interventions directed to individuals by health and social care systems should increase health and welfare of patients and customers. Aims: This paper aims to present and define a new concept Clinical Impact Research (CIR) and suggest which study design, either randomized controlled trial (RCT) (experimental) or benchmarking controlled trial (BCT) (observational) is recommendable and to consider the feasibility, validity, and generalizability issues in CIR. Methods: The new concept is based on a narrative review of the literature and on author’s idea that in intervention studies, there is a need to cover comprehensively all the main impact categories and their respective outcomes. The considerations on how to choose the most appropriate study design (RCT or BCT) were based on previous methodological studies on RCTs and BCTs and on author’s previous work on the concepts benchmarking controlled trial and system impact research (SIR). Results: The CIR covers all studies aiming to assess the impact for health and welfare of any health (and integrated social) care or public health intervention directed to an individual. The impact categories are accessibility, quality, equality, effectiveness, safety, and efficiency. Impact is the main concept, and within each impact category, both generic- and context-specific outcome measures are needed. CIR uses RCTs and BCTs. Conclusions: CIR should be given a high priority in medical, health care, and health economic research. Clinicians and leaders at all levels of health care can exploit the evidence from CIR. Key messagesThe new concept of Clinical Impact Research (CIR) is defined as a research field aiming to assess what are the impacts of healthcare and public health interventions targeted to patients or individuals.The term impact refers to all effects caused by the interventions, with particular emphasis on accessibility, quality, equality, effectiveness, safety, and efficiency. CIR uses two study designs: randomized controlled trials (RCTs) (experimental) and benchmarking controlled trials (BCTs) (observational). Suggestions on how to choose between RCT and BCT as the most suitable study design are presented.Simple way of determining the study question in CIR based on the PICO (patient, intervention, control intervention, outcome) framework is presented.CIR creates the scientific basis for clinical decisions. Clinicians and leaders at all levels of health care and those working for public health can use the evidence from CIR for the benefit of patients and the population. PMID:27494394

Clinical Impact Research - how to choose experimental or observational intervention study?

PubMed

Malmivaara, Antti

2016-11-01

Interventions directed to individuals by health and social care systems should increase health and welfare of patients and customers. This paper aims to present and define a new concept Clinical Impact Research (CIR) and suggest which study design, either randomized controlled trial (RCT) (experimental) or benchmarking controlled trial (BCT) (observational) is recommendable and to consider the feasibility, validity, and generalizability issues in CIR. The new concept is based on a narrative review of the literature and on author's idea that in intervention studies, there is a need to cover comprehensively all the main impact categories and their respective outcomes. The considerations on how to choose the most appropriate study design (RCT or BCT) were based on previous methodological studies on RCTs and BCTs and on author's previous work on the concepts benchmarking controlled trial and system impact research (SIR). The CIR covers all studies aiming to assess the impact for health and welfare of any health (and integrated social) care or public health intervention directed to an individual. The impact categories are accessibility, quality, equality, effectiveness, safety, and efficiency. Impact is the main concept, and within each impact category, both generic- and context-specific outcome measures are needed. CIR uses RCTs and BCTs. CIR should be given a high priority in medical, health care, and health economic research. Clinicians and leaders at all levels of health care can exploit the evidence from CIR. Key messages The new concept of Clinical Impact Research (CIR) is defined as a research field aiming to assess what are the impacts of healthcare and public health interventions targeted to patients or individuals. The term impact refers to all effects caused by the interventions, with particular emphasis on accessibility, quality, equality, effectiveness, safety, and efficiency. CIR uses two study designs: randomized controlled trials (RCTs) (experimental) and benchmarking controlled trials (BCTs) (observational). Suggestions on how to choose between RCT and BCT as the most suitable study design are presented. Simple way of determining the study question in CIR based on the PICO (patient, intervention, control intervention, outcome) framework is presented. CIR creates the scientific basis for clinical decisions. Clinicians and leaders at all levels of health care and those working for public health can use the evidence from CIR for the benefit of patients and the population.

Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review.

PubMed

Keller, Sara C; Tamma, Pranita D; Cosgrove, Sara E; Miller, Melissa A; Sateia, Heather; Szymczak, Julie; Gurses, Ayse P; Linder, Jeffrey A

2018-01-01

In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS. © Copyright 2018 by the American Board of Family Medicine.

Rapid-Testing Technology and Systems Improvement for the Elimination of Congenital Syphilis in Haiti: Overcoming the “Technology to Systems Gap”

PubMed Central

Benoit, Daphne; Zhou, Xi K.; Pape, Jean W.; Peeling, Rosanna W.; Fitzgerald, Daniel W.; Mate, Kedar S.

2013-01-01

Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after (P < 0.001) and further increased to 96.8% (P < 0.001) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests (P = 0.27), but it improved significantly from 70.2% to 84.3% (P < 0.001) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches. PMID:26316955

Rapid-Testing Technology and Systems Improvement for the Elimination of Congenital Syphilis in Haiti: Overcoming the "Technology to Systems Gap".

PubMed

Severe, Linda; Benoit, Daphne; Zhou, Xi K; Pape, Jean W; Peeling, Rosanna W; Fitzgerald, Daniel W; Mate, Kedar S

2013-01-01

Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after (P < 0.001) and further increased to 96.8% (P < 0.001) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests (P = 0.27), but it improved significantly from 70.2% to 84.3% (P < 0.001) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches.

A multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention in nursing homes: a two-armed randomized controlled trial.

PubMed

Beeckman, Dimitri; Clays, Els; Van Hecke, Ann; Vanderwee, Katrien; Schoonhoven, Lisette; Verhaeghe, Sofie

2013-04-01

Frail older people admitted to nursing homes are at risk of a range of adverse outcomes, including pressure ulcers. Clinical decision support systems are believed to have the potential to improve care and to change the behaviour of healthcare professionals. To determine whether a multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention improves adherence to recommendations for pressure ulcer prevention in nursing homes. Two-armed randomized controlled trial in a nursing home setting in Belgium. The trial consisted of a 16-week implementation intervention between February and June 2010, including one baseline, four intermediate, and one post-testing measurement. Primary outcome was the adherence to guideline-based care recommendations (in terms of allocating adequate pressure ulcer prevention in residents at risk). Secondary outcomes were the change in resident outcomes (pressure ulcer prevalence) and intermediate outcomes (knowledge and attitudes of healthcare professionals). Random sample of 11 wards (6 experimental; 5 control) in a convenience sample of 4 nursing homes in Belgium. In total, 464 nursing home residents and 118 healthcare professionals participated. The experimental arm was involved in a multi-faceted tailored implementation intervention of a clinical decision support system, including interactive education, reminders, monitoring, feedback and leadership. The control arm received a hard-copy of the pressure ulcer prevention protocol, supported by standardized 30 min group lecture. Patients in the intervention arm were significantly more likely to receive fully adequate pressure ulcer prevention when seated in a chair (F=16.4, P=0.003). No significant improvement was observed on pressure ulcer prevalence and knowledge of the professionals. While baseline attitude scores were comparable between both groups [exp. 74.3% vs. contr. 74.5% (P=0.92)], the mean score after the intervention was 83.5% in the experimental group vs. 72.1% in the control group (F=15.12, P<0.001). The intervention was only partially successful to improve the primary outcome. Attitudes improved significantly while the knowledge of the healthcare workers remained unsatisfactorily low. Further research should focus on the underlying reasons for these findings. Copyright © 2012 Elsevier Ltd. All rights reserved.

A randomized control trial of interventions in school-aged children with auditory processing disorders.

PubMed

Sharma, Mridula; Purdy, Suzanne C; Kelly, Andrea S

2012-07-01

The primary purpose of the study was to compare intervention approaches for children with auditory processing disorder (APD): bottom-up training including activities focused on auditory perception, discrimination, and phonological awareness, and top-down training including a range of language activities. Another purpose was to determine the benefits of personal FM systems. The study is a randomized control trial where participants were allocated to groups receiving one of the two interventions, with and without personal FM, or to the no intervention group. The six-week intervention included weekly one-hour sessions with a therapist in the clinic, plus 1-2 hours per week of parent-directed homework. 55 children (7 to 13 years) with APD participated in the study. Intervention outcomes included reading, language, and auditory processing. Positive outcomes were observed for both training approaches and personal FM systems on several measures. Pre-intervention nonverbal IQ, age, and severity of APD did not influence outcomes. Performance of control group participants did not change when retested after the intervention period. Both intervention approaches were beneficial and there were additional benefits with the use of personal FM. Positive results were not limited to the areas specifically targeted by the interventions.

What's the Point?: A Review of Reward Systems Implemented in Gamification Interventions.

PubMed

Lewis, Zakkoyya H; Swartz, Maria C; Lyons, Elizabeth J

2016-04-01

Rewards are commonly used in interventions to change behavior, but they can inhibit development of intrinsic motivation, which is associated with long-term behavior maintenance. Gamification is a novel intervention strategy that may target intrinsic motivation through fun and enjoyment. Before the effects of gamified interventions on motivation can be determined, there must be an understanding of how gamified interventions operationalize rewards, such as point systems. The purpose of this review is to determine the prevalence of different reward types, specifically point systems, within gamified interventions. Electronic databases were searched for relevant articles. Data sources included Medline OVID, Medline PubMed, Web of Science, CINAHL, Cochrane Central, and PsycINFO. Out of the 21 articles retrieved, 18 studies described a reward system and were included in this review. Gamified interventions were designed to target a myriad of clinical outcomes across diverse populations. Rewards included points (n = 14), achievements/badges/medals (n = 7), tangible rewards (n = 7), currency (n = 4), other unspecified rewards (n = 3), likes (n = 2), animated feedback (n = 1), and kudos (n = 1). Rewards, and points in particular, appear to be a foundational component of gamified interventions. Despite their prevalence, authors seldom described the use of noncontingent rewards or how the rewards interacted with other game features. The reward systems relying on tangible rewards and currency may have been limited by inhibited intrinsic motivation. As gamification proliferates, future research should explicitly describe how rewards were operationalized in the intervention and evaluate the effects of gamified rewards on motivation across populations and research outcomes.

Economic evaluations of clinical pharmacist interventions on hospital inpatients: a systematic review of recent literature.

PubMed

Gallagher, James; McCarthy, Suzanne; Byrne, Stephen

2014-12-01

Clinical and cost-effectiveness evidence are needed to justify the existence or extension of routine clinical pharmacy services in hospital settings. Previous reviews have indicated that clinical pharmacist interventions are likely to have a positive economic impact on hospital budgets but highlighted issues relating to the quality of studies. The primary aim of this review was to feature economic evaluations of clinical pharmacy services which targeted hospital inpatients. The review focused on the current cost-effectiveness status of different services, in addition to evaluating the quality of individual studies. Results of this systematic review were compared with cost-effectiveness and quality related findings of reviews which considered earlier time frames and alternative settings. A systematic review of the literature included a review of the following databases: Academic Search Complete, Cochrane Library, EconLit, Embase Elsevier, NHS Economic Evaluation Database and PubMed. Only studies with an economic assessment of a clinical pharmacy service provided in a hospital setting were included. Data relating to the cost-effectiveness was extracted from eligible studies. Methodologies employed and overall quality of the studies was also reviewed. A grading system was applied to determine the quality of studies. Consolidated Health Economic Evaluation Reporting Standards statement was employed to determine which aspects of a high quality health economic study were employed. Twenty studies were deemed eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15 %) were deemed to be "good-quality" studies. No 'novel'clinical pharmacist intervention was identified during the course of this review. Clinical pharmacy interventions continue to provide cost savings. However, the standard of studies published has stagnated or even deteriorated in comparison with those included in previous reviews. Utilisation of published guidelines at initial stages of future studies may help improve the overall quality of studies.

Initial clinical trial of a closed loop, fully automatic intra-aortic balloon pump.

PubMed

Kantrowitz, A; Freed, P S; Cardona, R R; Gage, K; Marinescu, G N; Westveld, A H; Litch, B; Suzuki, A; Hayakawa, H; Takano, T

1992-01-01

A new generation, closed loop, fully automatic intraaortic balloon pump (CL-IABP) system continuously optimizes diastolic augmentation by adjusting balloon pump parameters beat by beat without operator intervention. In dogs in sinus rhythm and with experimentally induced arrhythmias, the new CL-IABP system provided safe, effective augmentation. To investigate the system's suitability for clinical use, 10 patients meeting standard indications for IABP were studied. The patients were pumped by the fully automatic IABP system for an average of 20 hr (range, 1-48 hr). At start-up, the system optimized pumping parameters within 7-20 sec. Evaluation of 186 recordings made at hourly intervals showed that inflation began within 20 msec of the dicrotic notch 99% of the time. In 100% of the recordings, deflation straddled the first half of ventricular ejection. Peak pressure across the balloon membrane averaged 55 mmHg and, in no case, exceeded 100 mmHg. Examination of the data showed that as soon as the system was actuated it provided consistently beneficial diastolic augmentation without any further operator intervention. Eight patients improved and two died (one of irreversible cardiogenic shock and one of ischemic cardiomyopathy). No complications were attributable to the investigational aspects of the system. A fully automated IABP is feasible in the clinical setting, and it may have advantages relative to current generation IABP systems.

Registry Assessment of Peripheral Interventional Devices (RAPID): Registry assessment of peripheral interventional devices core data elements.

PubMed

Jones, W Schuyler; Krucoff, Mitchell W; Morales, Pablo; Wilgus, Rebecca W; Heath, Anne H; Williams, Mary F; Tcheng, James E; Marinac-Dabic, J Danica; Malone, Misti L; Reed, Terrie L; Fukaya, Rie; Lookstein, Robert A; Handa, Nobuhiro; Aronow, Herbert D; Bertges, Daniel J; Jaff, Michael R; Tsai, Thomas T; Smale, Joshua A; Zaugg, Margo J; Thatcher, Robert J; Cronenwett, Jack L

2018-02-01

The current state of evaluating patients with peripheral artery disease and more specifically of evaluating medical devices used for peripheral vascular intervention (PVI) remains challenging because of the heterogeneity of the disease process, the multiple physician specialties that perform PVI, the multitude of devices available to treat peripheral artery disease, and the lack of consensus about the best treatment approaches. Because PVI core data elements are not standardized across clinical care, clinical trials, and registries, aggregation of data across different data sources and physician specialties is currently not feasible. Under the auspices of the U.S. Food and Drug Administration's Medical Device Epidemiology Network initiative-and its PASSION (Predictable and Sustainable Implementation of the National Registries) program, in conjunction with other efforts to align clinical data standards-the Registry Assessment of Peripheral Interventional Devices (RAPID) workgroup was convened. RAPID is a collaborative, multidisciplinary effort to develop a consensus lexicon and to promote interoperability across clinical care, clinical trials, and national and international registries of PVI. The current manuscript presents the initial work from RAPID to standardize clinical data elements and definitions, to establish a framework within electronic health records and health information technology procedural reporting systems, and to implement an informatics-based approach to promote the conduct of pragmatic clinical trials and registry efforts in PVI. Ultimately, we hope this work will facilitate and improve device evaluation and surveillance for patients, clinicians, health outcomes researchers, industry, policymakers, and regulators. Copyright © 2017 Society for Vascular Surgery. All rights reserved.

Pain management interventions in the nursing home: a structured review of the literature.

PubMed

Herman, Adam D; Johnson, Theodore M; Ritchie, Christine S; Parmelee, Patricia A

2009-07-01

Residents in nursing homes (NHs) experience pain that is underrecognized and undertreated. This pain contributes to a decline in quality of life. Although descriptive studies of pain assessment and management have been conducted, few have been published that critically evaluate interventions to improve pain management. Identification of the strengths and gaps in the current literature is required. A literature search was conducted of clinical trials that evaluated prospective interventions to improve pain management. Information on the intervention type, resident sample and setting, endpoints, and study design were extracted. Studies were classified based on a modification of Donabedian's model of healthcare quality. Four categories of interventions were identified: actor, decision support, treatment, and systems. The search strategy and selection criteria yielded 21 articles. Eleven studies used an actor intervention; of these, eight also employed a systems intervention, and one also used a treatment intervention. Two studies used a decision support intervention, seven used a treatment intervention, and one used a systems intervention. The overall quality of research was uneven in several areas: research design--nine studies were quasi-experimental in nature, endpoints measures were not consistent--three did not perform statistical analysis, and characteristics of the resident samples varied dramatically. In conclusion, the number of high-quality studies of pain management in NHs remains limited. Process endpoints are used as surrogate measures for resident endpoints. Systematic approaches are needed to understand how each type of intervention improves the quality of pain management at the resident level.

Effective, clinically feasible and sustainable: Key design features of psycho-educational and supportive care interventions to promote individualised self-management in cancer care.

PubMed

Schofield, Penelope; Chambers, Suzanne

2015-05-01

As the global burden of cancer increases healthcare services will face increasing challenges in meet the complex needs of these patients, their families and the communities in which they live. This raises the question of how to meet patient need where direct clinical contact may be constrained or not readily available. Patients and families require resources and skills to manage their illness outside of the hospital setting within their own communities. To propose a framework for the development and delivery of psycho-educational and supportive care interventions drawing on theoretical principles of behaviour change and evidence-based interventions, and based on extensive experience in developing and testing complex interventions in oncology. At the core of this intervention framework are considerations of efficiency: interventions are designed to cater for individuals' unique needs; to place minimal demands on the health system infrastructure and to be rapidly disseminated into usual care if successful. There are seven key features: 1) Targeting cancer type and stage; 2) Tailoring to unique individual needs; 3) Promotion of patient self-management of their disease and treatment side effects; 4) Efficient delivery of the intervention; 5) Training and adherence to protocol; 6) Ensuring the intervention is evidence-based; 7) Confirming stakeholder acceptability of the intervention. A case study of a randomised controlled trial which tested psycho-educational oncology interventions using this framework is presented. These interventions were designed to cater for individuals' unique needs and promote self-management while placing minimal demands on the acute health care setting. Innovative ways to realise the potentially major impact that psycho-educational and supportive care interventions can have on psychological morbidity, coping, symptoms and quality of life in serious and chronic illness are needed. This framework, which is driven by theory, evidence, and experience, is designed to ensure that interventions are effective, clinically feasible and sustainable.

SU-E-J-185: A Systematic Review of Breathing Guidance in Radiation Oncology and Radiology

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pollock, S; Keall, P; Keall, R

Purpose: The advent of image-guided radiation therapy (IGRT) has led to dramatic improvements in the accuracy of treatment delivery in radiotherapy. Such advancements have highlighted the deleterious impact tumor motion can have on both image quality and radiation treatment delivery. One approach to reducing tumor motion is the use of breathing guidance systems during imaging and treatment. A review of such research had not yet been performed, it was therefore our aim to perform a systematic review of breathing guidance interventions within the fields of radiation oncology and radiology. Methods: Results of online database searches were filtered in accordance tomore » a set of eligibility criteria. The search, filtration, and analysis of articles were conducted in accordance with the PRISMAStatement reporting standard (Preferred Reporting Items for Systematic reviews and Meta-Analyses) utilizing the PICOS approach (Participants, Intervention, Comparison, Outcome, Study design). Participants: Cancer patients, healthy volunteers. Intervention: Biofeedback breathing guidance systems. Comparison: No breathing guidance of the same breathing type. Outcome: Regularity of breathing signal and anatomic/tumor motion, medical image quality, radiation treatment margins and coverage, medical imaging and radiation treatment times. Study design: Quantitative and controlled prospective or retrospective trials. Results: The systematic search yielded a total of 479 articles, which were filtered down to 27 relevant articles in accordance to the eligibility criteria. The vast majority of investigated outcomes were significantly positively impacted by the use of breathing guidance; however, this was dependent upon the nature of the breathing guidance system and study design. In 25/27 studies significant improvements from the use of breathing guidance were observed. Conclusion: The results found here indicate that further clinical studies are warranted which quantify more comprehensively the clinical impact of The results found here indicate that further clinical studies are warranted which quantify more comprehensively the clinical impact of breathing guidance interventions.« less

Usability Evaluation of a Clinical Decision Support System for Geriatric ED Pain Treatment.

PubMed

Genes, Nicholas; Kim, Min Soon; Thum, Frederick L; Rivera, Laura; Beato, Rosemary; Song, Carolyn; Soriano, Jared; Kannry, Joseph; Baumlin, Kevin; Hwang, Ula

2016-01-01

Older adults are at risk for inadequate emergency department (ED) pain care. Unrelieved acute pain is associated with poor outcomes. Clinical decision support systems (CDSS) hold promise to improve patient care, but CDSS quality varies widely, particularly when usability evaluation is not employed. To conduct an iterative usability and redesign process of a novel geriatric abdominal pain care CDSS. We hypothesized this process would result in the creation of more usable and favorable pain care interventions. Thirteen emergency physicians familiar with the Electronic Health Record (EHR) in use at the study site were recruited. Over a 10-week period, 17 1-hour usability test sessions were conducted across 3 rounds of testing. Participants were given 3 patient scenarios and provided simulated clinical care using the EHR, while interacting with the CDSS interventions. Quantitative System Usability Scores (SUS), favorability scores and qualitative narrative feedback were collected for each session. Using a multi-step review process by an interdisciplinary team, positive and negative usability issues in effectiveness, efficiency, and satisfaction were considered, prioritized and incorporated in the iterative redesign process of the CDSS. Video analysis was used to determine the appropriateness of the CDS appearances during simulated clinical care. Over the 3 rounds of usability evaluations and subsequent redesign processes, mean SUS progressively improved from 74.8 to 81.2 to 88.9; mean favorability scores improved from 3.23 to 4.29 (1 worst, 5 best). Video analysis revealed that, in the course of the iterative redesign processes, rates of physicians' acknowledgment of CDS interventions increased, however most rates of desired actions by physicians (such as more frequent pain score updates) decreased. The iterative usability redesign process was instrumental in improving the usability of the CDSS; if implemented in practice, it could improve geriatric pain care. The usability evaluation process led to improved acknowledgement and favorability. Incorporating usability testing when designing CDSS interventions for studies may be effective to enhance clinician use.

Optimizing Chronic Disease Management Mega-Analysis

PubMed Central

PATH-THETA Collaboration

2013-01-01

Background As Ontario’s population ages, chronic diseases are becoming increasingly common. There is growing interest in services and care models designed to optimize the management of chronic disease. Objective To evaluate the cost-effectiveness and expected budget impact of interventions in chronic disease cohorts evaluated as part of the Optimizing Chronic Disease Management mega-analysis. Data Sources Sector-specific costs, disease incidence, and mortality were calculated for each condition using administrative databases from the Institute for Clinical Evaluative Sciences. Intervention outcomes were based on literature identified in the evidence-based analyses. Quality-of-life and disease prevalence data were obtained from the literature. Methods Analyses were restricted to interventions that showed significant benefit for resource use or mortality from the evidence-based analyses. An Ontario cohort of patients with each chronic disease was constructed and followed over 5 years (2006–2011). A phase-based approach was used to estimate costs across all sectors of the health care system. Utility values identified in the literature and effect estimates for resource use and mortality obtained from the evidence-based analyses were applied to calculate incremental costs and quality-adjusted life-years (QALYs). Given uncertainty about how many patients would benefit from each intervention, a system-wide budget impact was not determined. Instead, the difference in lifetime cost between an individual-administered intervention and no intervention was presented. Results Of 70 potential cost-effectiveness analyses, 8 met our inclusion criteria. All were found to result in QALY gains and cost savings compared with usual care. The models were robust to the majority of sensitivity analyses undertaken, but due to structural limitations and time constraints, few sensitivity analyses were conducted. Incremental cost savings per patient who received intervention ranged between $15 per diabetic patient with specialized nursing to $10,665 per patient wth congestive heart failure receiving in-home care. Limitations Evidence used to inform estimates of effect was often limited to a single trial with limited generalizability across populations, interventions, and health care systems. Because of the low clinical fidelity of health administrative data sets, intermediate clinical outcomes could not be included. Cohort costs included an average of all health care costs and were not restricted to costs associated with the disease. Intervention costs were based on resource use specified in clinical trials. Conclusions Applying estimates of effect from the evidence-based analyses to real-world resource use resulted in cost savings for all interventions. On the basis of quality-of-life data identified in the literature, all interventions were found to result in a greater QALY gain than usual care would. Implementation of all interventions could offer significant cost reductions. However, this analysis was subject to important limitations. Plain Language Summary Chronic diseases are the leading cause of death and disability in Ontario. They account for a third of direct health care costs across the province. This study aims to evaluate the cost-effectiveness of health care interventions that might improve the management of chronic diseases. The evaluated interventions led to lower costs and better quality of life than usual care. Offering these options could reduce costs per patient. However, the studies used in this analysis were of medium to very low quality, and the methods had many limitations. PMID:24228076

[A computerised clinical decision-support system for the management of depression in Primary Care].

PubMed

Aragonès, Enric; Comín, Eva; Cavero, Myriam; Pérez, Víctor; Molina, Cristina; Palao, Diego

Despite its clinical relevance and its importance as a public health problem, there are major gaps in the management of depression. Evidence-based clinical guidelines are useful to improve processes and clinical outcomes. In order to make their implementation easier these guidelines have been transformed into computerised clinical decision support systems. In this article, a description is presented on the basics and characteristics of a new computerised clinical guideline for the management of major depression, developed in the public health system in Catalonia. This tool helps the clinician to establish reliable and accurate diagnoses of depression, to choose the best treatment a priori according to the disease and the patient characteristics. It also emphasises the importance of systematic monitoring to assess the clinical course, and to adjust therapeutic interventions to the patient's needs at all times. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

Percutaneous transhepatic biliary drainage assisted by real-time virtual sonography: a retrospective study

PubMed Central

2013-01-01

Background Real-time virtual sonography (RVS) is a diagnostic imaging support system that can synchronize with ultrasound images in conjunction with computed tomography or magnetic resonance images using magnetic navigation system. RVS has been applied in clinical practice to perform such procedures as radiofrequency ablation and biopsy; however, the application of RVS for percutaneous transhepatic biliary drainage (PTBD) is rare. Methods Between 2007 and 2012, RVS-assisted PTBD was performed for 30 patients (19 males and 11 females; age range, 41 to 89 years; mean age, 66.9 years) with obstructive jaundice. The targeted bile duct was determined using the RVS system before the procedure. The intervention was considered to be successful when the targeted bile duct was punctured and the drainage catheter was placed in the bile duct. Complications were evaluated according to the Society of Interventional Radiology Clinical Practice Guidelines. Results A total of 37 interventions were performed for 30 patients. The interventions were successful in 35 (95%) of 37 interventions. The targeted bile ducts were: B3 (n = 24), B5 (n = 7), B8 (n = 3), B6 (n = 1), and the anterior (n = 1) and posterior (n = 1) branches of the right bile duct. The mean targeted bile duct diameter was 4.9 mm (1.9 to 8.2 mm). PTBD was able to be accomplished in all patients because the non-targeted bile ducts were successfully punctured alternatively. No major complications were observed in relation to the interventional procedure. Conclusions RVS-assisted PTBD is a feasible and safe procedure. Accurate puncture of targeted bile ducts can be achieved using this method. PMID:23941632

Using 'nudge' principles for order set design: a before and after evaluation of an electronic prescribing template in critical care.

PubMed

Bourdeaux, Christopher P; Davies, Keith J; Thomas, Matthew J C; Bewley, Jeremy S; Gould, Timothy H

2014-05-01

Computerised order sets have the potential to reduce clinical variation and improve patient safety but the effect is variable. We sought to evaluate the impact of changes to the design of an order set on the delivery of chlorhexidine mouthwash and hydroxyethyl starch (HES) to patients in the intensive care unit. The study was conducted at University Hospitals Bristol NHS Foundation Trust, UK. Our intensive care unit uses a clinical information system (CIS). All drugs and fluids are prescribed with the CIS and drug and fluid charts are stored within a database. Chlorhexidine mouthwash was added as a default prescription to the prescribing template in January 2010. HES was removed from the prescribing template in April 2009. Both interventions were available to prescribe manually throughout the study period. We conducted a database review of all patients eligible for each intervention before and after changes to the configuration of choices within the prescribing system. 2231 ventilated patients were identified as appropriate for treatment with chlorhexidine, 591 before the intervention and 1640 after. 55.3% were prescribed chlorhexidine before the change and 90.4% after (p<0.001). 6199 patients were considered in the HES intervention, 2177 before the intervention and 4022 after. The mean volume of HES infused per patient fell from 630 mL to 20 mL after the change (p<0.001) and the percentage of patients receiving HES fell from 54.1% to 3.1% (p<0.001). These results were well sustained with time. The presentation of choices within an electronic prescribing system influenced the delivery of evidence-based interventions in a predictable way and the effect was well sustained. This approach has the potential to enhance the effectiveness of computerised order sets.

A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?

PubMed

Rawson, T M; Moore, L S P; Hernandez, B; Charani, E; Castro-Sanchez, E; Herrero, P; Hayhoe, B; Hope, W; Georgiou, P; Holmes, A H

2017-08-01

Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Interventions for the management of radiotherapy-induced xerostomia and hyposalivation: A systematic review and meta-analysis.

PubMed

Mercadante, Valeria; Al Hamad, Arwa; Lodi, Giovanni; Porter, Stephen; Fedele, Stefano

2017-03-01

Salivary gland hypofunction is a common and permanent adverse effect of radiotherapy to the head and neck. Randomised trials of available treatment modalities have produced unclear results and offer little reliable guidance for clinicians to inform evidence-based therapy. We have undertaken this systematic review and meta-analysis to estimate the effectiveness of available interventions for radiotherapy-induced xerostomia and hyposalivation. We searched MEDLINE, Cochrane Central, EMBASE, AMED, and CINAHL database through July 2016 for randomised controlled trials comparing any topical or systemic intervention to active and/or non-active controls for the treatment of radiotherapy-induced xerostomia. The results of clinically and statistically homogenous studies were pooled and meta-analyzed. 1732 patients from twenty studies were included in the systematic review. Interventions included systemic or topical pilocarpine, systemic cevimeline, saliva substitutes/mouthcare systems, hyperthermic humidification, acupuncture, acupuncture-like transcutaneous electrical nerve stimulation, low-level laser therapy and herbal medicine. Results from the meta-analysis, which included six studies, suggest that both cevimeline and pilocarpine can reduce xerostomia symptoms and increase salivary flow compared to placebo, although some aspects of the relevant effect size, duration of the benefit, and clinical meaningfulness remain unclear. With regard to interventions not included in the meta-analysis, we found no evidence, or very weak evidence, that they can reduce xerostomia symptoms or increase salivary flow in this population. Pilocarpine and cevimeline should represent the first line of therapy in head and neck cancer survivors with radiotherapy-induced xerostomia and hyposalivation. The use of other treatment modalities cannot be supported on the basis of current evidence. Copyright © 2017 Elsevier Ltd. All rights reserved.

C-arm Cone Beam Computed Tomography: A New Tool in the Interventional Suite.

PubMed

Raj, Santhosh; Irani, Farah Gillan; Tay, Kiang Hiong; Tan, Bien Soo

2013-11-01

C-arm Cone Beam CT (CBCT) is a technology that is being integrated into many of the newer angiography systems in the interventional suite. Due to its ability to provide cross sectional imaging, it has opened a myriad of opportunities for creating new clinical applications. We review the technical aspects, current reported clinical applications and potential benefits of this technology. Searches were made via PubMed using the string "CBCT", "Cone Beam CT", "Cone Beam Computed Tomography" and "C-arm Cone Beam Computed Tomography". All relevant articles in the results were reviewed. CBCT clinical applications have been reported in both vascular and non-vascular interventions. They encompass many aspects of a procedure including preprocedural planning, intraprocedural guidance and postprocedural assessment. As a result, they have allowed the interventionalist to be safer and more accurate in performing image guided procedures. There are however several technical limitations. The quality of images produced is not comparable to conventional computed tomography (CT). Radiation doses are also difficult to quantify when compared to CT and fluoroscopy. CBCT technology in the interventional suite has contributed significant benefits to the patient despite its current limitations. It is a tool that will evolve and potentially become an integral part of imaging guidance for intervention.

Non-technical skills training to enhance patient safety.

PubMed

Gordon, Morris

2013-06-01

  Patient safety is an increasingly recognised issue in health care. Systems-based and organisational methods of quality improvement, as well as education focusing on key clinical areas, are common, but there are few reports of educational interventions that focus on non-technical skills to address human factor sources of error. A flexible model for non-technical skills training for health care professionals has been designed based on the best available evidence, and with sound theoretical foundations.   Educational sessions to improve non-technical skills in health care have been described before. The descriptions lack the details to allow educators to replicate and innovate further.   A non-technical skills training course that can be delivered as either a half- or full-day intervention has been designed and delivered to a number of mixed groups of undergraduate medical students and doctors in postgraduate training. Participant satisfaction has been high and patient safety attitudes have improved post-intervention.   This non-technical skills educational intervention has been built on a sound evidence base, and is described so as to facilitate replication and dissemination. With the key themes laid out, clinical educators will be able to build interventions focused on numerous clinical issues that pay attention to human factor contributors to safety. © 2013 John Wiley & Sons Ltd.

Promoting Therapists' Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation.

PubMed

Levac, Danielle E; Glegg, Stephanie M N; Sveistrup, Heidi; Colquhoun, Heather; Miller, Patricia; Finestone, Hillel; DePaul, Vincent; Harris, Jocelyn E; Velikonja, Diana

2016-01-01

Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use. A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists' confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists' perspectives on MLS use during VR-based therapy provision. The intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists' clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach. The KT intervention improved therapists' confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy.

Promoting Therapists’ Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation

PubMed Central

Levac, Danielle E.; Glegg, Stephanie M. N.; Sveistrup, Heidi; Colquhoun, Heather; Miller, Patricia; Finestone, Hillel; DePaul, Vincent; Harris, Jocelyn E.; Velikonja, Diana

2016-01-01

Purpose Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use. Method A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists’ confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists’ perspectives on MLS use during VR-based therapy provision. Results The intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists’ clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach. Conclusion The KT intervention improved therapists’ confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy. PMID:27992492

A multi-data source surveillance system to detect a bioterrorism attack during the G8 Summit in Scotland.

PubMed

Meyer, N; McMenamin, J; Robertson, C; Donaghy, M; Allardice, G; Cooper, D

2008-07-01

In 18 weeks, Health Protection Scotland (HPS) deployed a syndromic surveillance system to early-detect natural or intentional disease outbreaks during the G8 Summit 2005 at Gleneagles, Scotland. The system integrated clinical and non-clinical datasets. Clinical datasets included Accident & Emergency (A&E) syndromes, and General Practice (GPs) codes grouped into syndromes. Non-clinical data included telephone calls to a nurse helpline, laboratory test orders, and hotel staff absenteeism. A cumulative sum-based detection algorithm and a log-linear regression model identified signals in the data. The system had a fax-based track for real-time identification of unusual presentations. Ninety-five signals were triggered by the detection algorithms and four forms were faxed to HPS. Thirteen signals were investigated. The system successfully complemented a traditional surveillance system in identifying a small cluster of gastroenteritis among the police force and triggered interventions to prevent further cases.

Evaluation of an ontology-based system for computerized cognitive rehabilitation.

PubMed

Alloni, Anna; Quaglini, Silvana; Panzarasa, Silvia; Sinforiani, Elena; Bernini, Sara

2018-07-01

This paper describes the results of a randomized clinical trial about the effectiveness of a computerized rehabilitation treatment on a sample of 31 patients affected by Parkinson disease. Computerized exercises were administered by the therapists to the intervention group (n = 17) through the CoRe tool, which automatically generates a big variety of exercises leveraging on a stimuli set (words, sounds and images) organized into a dedicated ontology. A battery of standard neuropsychological tests was performed for patients' assessment at baseline, after the treatment (that lasted 1 month), and after 6 months from the treatment stop. The control group underwent a sham intervention. Results show a statistically significant clinical benefit from computerized rehabilitation with respect to sham treatment. For the intervention group, response time and response accuracy were integrated into a weighted score that accounts also for the specific cognitive burden of each exercise. Differently from the control group, the majority of patients in the intervention group showed an improvement in that score, more marked in the first week of treatment, and which lasts for the entire treatment period, which could account both for a quick learning effect and for an improvement of cognitive conditions. Good usability of CoRe, already observed in previous studies, was confirmed by the present trial, where the percentage of protocol completion in the intervention group is very high (all but one patient are above 90%). The CoRe system showed to be effective to improve some cognitive abilities in patients with Parkinson disease. However, after the end of the training, the benefit is hardly maintained over time. These findings support the implementation of CoRe in the clinical routine and the continuation of the treatment after discharge through the use of a homecare version of the system. Copyright © 2018 Elsevier B.V. All rights reserved.

Anser EMT: the first open-source electromagnetic tracking platform for image-guided interventions.

PubMed

Jaeger, Herman Alexander; Franz, Alfred Michael; O'Donoghue, Kilian; Seitel, Alexander; Trauzettel, Fabian; Maier-Hein, Lena; Cantillon-Murphy, Pádraig

2017-06-01

Electromagnetic tracking is the gold standard for instrument tracking and navigation in the clinical setting without line of sight. Whilst clinical platforms exist for interventional bronchoscopy and neurosurgical navigation, the limited flexibility and high costs of electromagnetic tracking (EMT) systems for research investigations mitigate against a better understanding of the technology's characterisation and limitations. The Anser project provides an open-source implementation for EMT with particular application to image-guided interventions. This work provides implementation schematics for our previously reported EMT system which relies on low-cost acquisition and demodulation techniques using both National Instruments and Arduino hardware alongside MATLAB support code. The system performance is objectively compared to other commercial tracking platforms using the Hummel assessment protocol. Positional accuracy of 1.14 mm and angular rotation accuracy of [Formula: see text] are reported. Like other EMT platforms, Anser is susceptible to tracking errors due to eddy current and ferromagnetic distortion. The system is compatible with commercially available EMT sensors as well as the Open Network Interface for image-guided therapy (OpenIGTLink) for easy communication with visualisation and medical imaging toolkits such as MITK and 3D Slicer. By providing an open-source platform for research investigations, we believe that novel and collaborative approaches can overcome the limitations of current EMT technology.

Family Health Conversations: How Do They Support Health?

PubMed Central

Benzein, Eva

2014-01-01

Research shows that living with illness can be a distressing experience for the family and may result in suffering and reduced health. To meet families' needs, family systems intervention models are developed and employed in clinical contexts. For successful refinement and implementation it is important to understand how these models work. The aim of this study was therefore to describe the dialogue process and possible working mechanisms of one systems nursing intervention model, the Family Health Conversation model. A descriptive evaluation design was applied and 15 transcribed conversations with five families were analyzed within a hermeneutic tradition. Two types of interrelated dialogue events were identified: narrating and exploring. There was a flow between these events, a movement that was generated by the interaction between the participants. Our theoretically grounded interpretation showed that narrating, listening, and reconsidering in interaction may be understood as supporting family health by offering the families the opportunity to constitute self-identity and identity within the family, increasing the families' understanding of multiple ways of being and acting, to see new possibilities and to develop meaning and hope. Results from this study may hopefully contribute to the successful implementation of family systems interventions in education and clinical praxis. PMID:24800068

In vivo validation of a 3D ultrasound system for imaging the lateral ventricles of neonates

NASA Astrophysics Data System (ADS)

Kishimoto, J.; Fenster, A.; Chen, N.; Lee, D.; de Ribaupierre, S.

2014-03-01

Dilated lateral ventricles in neonates can be due to many different causes, such as brain loss, or congenital malformation; however, the main cause is hydrocephalus, which is the accumulation of fluid within the ventricular system. Hydrocephalus can raise intracranial pressure resulting in secondary brain damage, and up to 25% of patients with severely enlarged ventricles have epilepsy in later life. Ventricle enlargement is clinically monitored using 2D US through the fontanels. The sensitivity of 2D US to dilation is poor because it cannot provide accurate measurements of irregular volumes such as the ventricles, so most clinical evaluations are of a qualitative nature. We developed a 3D US system to image the cerebral ventricles of neonates within the confines of incubators that can be easily translated to more open environments. Ventricle volumes can be segmented from these images giving a quantitative volumetric measurement of ventricle enlargement without moving the patient into an imaging facility. In this paper, we report on in vivo validation studies: 1) comparing 3D US ventricle volumes before and after clinically necessary interventions removing CSF, and 2) comparing 3D US ventricle volumes to those from MRI. Post-intervention ventricle volumes were less than pre-intervention measurements for all patients and all interventions. We found high correlations (R = 0.97) between the difference in ventricle volume and the reported removed CSF with the slope not significantly different than 1 (p < 0.05). Comparisons between ventricle volumes from 3D US and MR images taken 4 (±3.8) days of each other did not show significant difference (p=0.44) between 3D US and MRI through paired t-test.

β-Thalassemia Intermedia: A Clinical Perspective

PubMed Central

Musallam, Khaled M.; Taher, Ali T.; Rachmilewitz, Eliezer A.

2012-01-01

Our understanding of the molecular and pathophysiological mechanisms underlying the disease process in patients with β-thalassemia intermedia has substantially increased over the past decade. Earlier studies observed that patients with β-thalassemia intermedia experience a clinical-complications profile that is different from that in patients with β-thalassemia major. In this article, a variety of clinical morbidities are explored, and their associations with the underlying disease pathophysiology and risk factors are examined. These involve several organs and organ systems including the vasculature, heart, liver, endocrine glands, bone, and the extramedullary hematopoietic system. The effects of some therapeutic interventions on the development of clinical complications are also discussed. PMID:22762026

Upper gastrointestinal bleeding risk scores: Who, when and why?

PubMed Central

Monteiro, Sara; Gonçalves, Tiago Cúrdia; Magalhães, Joana; Cotter, José

2016-01-01

Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact. PMID:26909231

Identifying Nursing Interventions in a Cancer Screening Program Using Nursing Interventions Classification Taxonomy.

PubMed

Benito, Llucia; Lluch, María Teresa; Falcó, Anna Marta; García, Montse; Puig, Montse

2017-04-01

This study aimed to investigate which Nursing Interventions Classification (NIC) labels correspond to specific nursing interventions provided during cancer screening to establish a nursing documentation system. This descriptive study was conducted to identify and classify the interventions that cancer screening nurses perform based on an initial list. The initial list was grouped into 15 interventions that corresponded to four domains and eight classes. The study found expert consensus regarding the duties of cancer screening nurses and identified 15 interventions that should be implemented in clinical practice for cancer screening care, according to the NIC taxonomy. This study is the first step in developing indicators to assess nursing performance in cancer screening, and it helps to establish the core competency requirements for cancer screening nurses. © 2015 NANDA International, Inc.

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback.

PubMed

Bailie, Ross S; Togni, Samantha J; Si, Damin; Robinson, Gary; d'Abbs, Peter H N

2003-07-30

Interventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia. The intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management. Levels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period. Improvements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.

Use of a pharmacy technician to facilitate postfracture care provided by clinical pharmacy specialists.

PubMed

Irwin, Adriane N; Heilmann, Rachel M F; Gerrity, Theresa M; Kroner, Beverly A; Olson, Kari L

2014-12-01

The ability of a pharmacy technician to support the patient screening and documentation-related functions of a pharmacist-driven osteoporosis management service was evaluated. A two-phase prospective study was conducted within a large integrated health system to assess a pharmacy technician's performance in supporting a multisite team of clinical pharmacy specialists providing postfracture care. In phase I of the study, a specially trained pharmacy technician provided support to pharmacists at five participating medical offices, helping to identify patients requiring pharmacist intervention and, when applicable, collecting patient-specific clinical information from the electronic health record. In phase II of the study, the amount of pharmacist time saved through the use of technician support versus usual care was evaluated. The records of 127 patient cases were reviewed by the pharmacy technician during phase I of the study, and a pharmacist agreed with the technician's determination of the need for intervention in the majority of instances (92.9%). An additional 91 patient cases were reviewed by the technician in phase II of the research. With technician support, pharmacists spent less time reviewing cases subsequently determined as not requiring intervention (mean ± S.D., 5.0 ± 3.8 minutes per case compared with 5.2 ± 4.5 minutes under the usual care model; p = 0.78). In cases requiring intervention, technician support was associated with a reduction in the average pharmacist time spent on care plan development (13.5 ± 7.1 minutes versus 18.2 ± 16.6 minutes with usual care, p = 0.34). The study results suggest that a pharmacy technician can accurately determine if a patient is a candidate for pharmacist intervention and collect clinical information to facilitate care plan development. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Implementing a Measurement Feedback System: A Tale of Two Sites

PubMed Central

Douglas, Susan R.; Vides De Andrade, Ana Regina; Tomlinson, Michele; Gleacher, Alissa; Olin, Serene; Hoagwood, Kimberly

2015-01-01

A randomized experiment was conducted in two outpatient clinics evaluating a measurement feedback system called contextualized feedback systems. The clinicians of 257 Youth 11–18 received feedback on progress in mental health symptoms and functioning either every 6 months or as soon as the youth’s, clinician’s or caregiver’s data were entered into the system. The ITT analysis showed that only one of the two participating clinics (Clinic R) had an enhanced outcome because of feedback, and only for the clinicians’ ratings of youth symptom severity on the SFSS. A dose–response effect was found only for Clinic R for both the client and clinician ratings. Implementation analyses showed that Clinic R had better implementation of the feedback intervention. Clinicians’ questionnaire completion rate and feedback viewing at Clinic R were 50 % higher than clinicians at Clinic U. The discussion focused on the differences in implementation at each site and how these differences may have contributed to the different outcomes of the experiment. PMID:25876736

Using an internet intervention to support self-management of low back pain in primary care: findings from a randomised controlled feasibility trial (SupportBack)

PubMed Central

Geraghty, Adam W A; Stanford, Rosie; Stuart, Beth; Little, Paul; Roberts, Lisa C; Foster, Nadine E; Hill, Jonathan C; Hay, Elaine M; Turner, David; Malakan, Wansida; Leigh, Linda; Yardley, Lucy

2018-01-01

Objective To determine the feasibility of a randomised controlled trial of an internet intervention for low back pain (LBP) using three arms: (1) usual care, (2) usual care plus an internet intervention or (3) usual care plus an internet intervention with additional physiotherapist telephone support. Design and setting A three-armed randomised controlled feasibility trial conducted in 12 general practices in England. Participants Primary care patients aged over 18 years, with current LBP, access to the internet and without indicators of serious spinal pathology or systemic illness. Interventions The ‘SupportBack’ internet intervention delivers a 6-week, tailored programme, focused on graded goal setting, self-monitoring and provision of tailored feedback to encourage physical activity. Additional physiotherapist telephone support consisted of three brief telephone calls over a 4-week period, to address any concerns and provide reassurance. Outcomes The primary outcomes were the feasibility of the trial design including recruitment, adherence and retention at follow-up. Secondary descriptive and exploratory analyses were conducted on clinical outcomes including LBP-related disability at 3 months follow-up. Results Primary outcomes: 87 patients with LBP were recruited (target 60–90) over 6 months, and there were 3 withdrawals. Adherence to the intervention was higher in the physiotherapist-supported arm, compared with the stand-alone internet intervention. Trial physiotherapists adhered to the support protocol. Overall follow-up rate on key clinical outcomes at 3 months follow-up was 84%. Conclusions This study demonstrated the feasibility of a future definitive randomised controlled trial to determine the clinical and cost-effectiveness of the SupportBack intervention in primary care patients with LBP. Trial registration number ISRCTN31034004; Results. PMID:29525768

Internet-delivered Treatment for Substance Abuse: A Multi-site Randomized Controlled Clinical Trial

PubMed Central

Campbell, Aimee N. C.; Nunes, Edward V.; Matthews, Abigail G.; Stitzer, Maxine; Miele, Gloria M.; Polsky, Daniel; Turrigiano, Eva; Walters, Scott; McClure, Erin A.; Kyle, Tiffany L.; Wahle, Aimee; Van Veldhuisen, Paul; Goldman, Bruce; Babcock, Dean; Stabile, Patricia Quinn; Winhusen, Theresa; Ghitza, Udi E.

2014-01-01

Objective Drug and alcohol abuse constitutes a major public health problem. Computer-delivered interventions have potential to improve access to quality care. The objective of this study was to evaluate the effectiveness of the Therapeutic Education System, an internet-delivered behavioral intervention that includes motivational incentives, as a clinician-extender in the treatment of substance use disorders. Method Adult men and women (N=507) entering 10 outpatient addiction treatment programs were randomly assigned to 12-weeks of treatment-as-usual (n=252) or treatment-as-usual + Therapeutic Education System, whereby the intervention substituted for 2 hours of standard care per week (n=255). Therapeutic Education System consists of 62 computer-interactive modules covering skills for achieving and maintaining abstinence, plus prize-based motivational incentives contingent on abstinence and treatment adherence. Treatment-as-usual consisted of individual and group counseling at the participating programs. Primary outcomes were (1) abstinence from drugs and heavy drinking measured by twice weekly urine drug screens and self-report, and (2) time to drop-out from treatment. Results Compared to treatment-as-usual, those receiving Therapeutic Education System reduced dropout from treatment (Hazard Ratio=0.72 [95% CI, 0.57-0.92], P=.010), and increased abstinence (Odds Ratio=1.62 [95% CI: 1.12-2.35], P=.010), an effect that was more pronounced among patients with a positive urine drug and/or breath alcohol screen at the point of study entry (n=228) (Odds Ratio=2.18 [95% CI: 1.30-3.68], P=.003). Conclusion Internet-delivered interventions, such as Therapeutic Education System, have the potential to expand access and improve addiction treatment outcomes; additional research is needed to assess effectiveness in non-specialty clinical systems and to differentiate the effect of Community Reinforcement Approach and Contingency Management. PMID:24700332

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach.

PubMed

Ward, Marie; McAuliffe, Eilish; Wakai, Abel; Geary, Una; Browne, John; Deasy, Conor; Schull, Michael; Boland, Fiona; McDaid, Fiona; Coughlan, Eoin; O'Sullivan, Ronan

2017-01-23

Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED). A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of 'Plan Do Study Act' (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed. Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

Evaluation of scoring models for identifying the need for therapeutic intervention of upper gastrointestinal bleeding: A new prediction score model for Japanese patients.

PubMed

Iino, Chikara; Mikami, Tatsuya; Igarashi, Takasato; Aihara, Tomoyuki; Ishii, Kentaro; Sakamoto, Jyuichi; Tono, Hiroshi; Fukuda, Shinsaku

2016-11-01

Multiple scoring systems have been developed to predict outcomes in patients with upper gastrointestinal bleeding. We determined how well these and a newly established scoring model predict the need for therapeutic intervention, excluding transfusion, in Japanese patients with upper gastrointestinal bleeding. We reviewed data from 212 consecutive patients with upper gastrointestinal bleeding. Patients requiring endoscopic intervention, operation, or interventional radiology were allocated to the therapeutic intervention group. Firstly, we compared areas under the curve for the Glasgow-Blatchford, Clinical Rockall, and AIMS65 scores. Secondly, the scores and factors likely associated with upper gastrointestinal bleeding were analyzed with a logistic regression analysis to form a new scoring model. Thirdly, the new model and the existing model were investigated to evaluate their usefulness. Therapeutic intervention was required in 109 patients (51.4%). The Glasgow-Blatchford score was superior to both the Clinical Rockall and AIMS65 scores for predicting therapeutic intervention need (area under the curve, 0.75 [95% confidence interval, 0.69-0.81] vs 0.53 [0.46-0.61] and 0.52 [0.44-0.60], respectively). Multivariate logistic regression analysis retained seven significant predictors in the model: systolic blood pressure <100 mmHg, syncope, hematemesis, hemoglobin <10 g/dL, blood urea nitrogen ≥22.4 mg/dL, estimated glomerular filtration rate ≤ 60 mL/min per 1.73 m 2 , and antiplatelet medication. Based on these variables, we established a new scoring model with superior discrimination to those of existing scoring systems (area under the curve, 0.85 [0.80-0.90]). We developed a superior scoring model for identifying therapeutic intervention need in Japanese patients with upper gastrointestinal bleeding. © 2016 Japan Gastroenterological Endoscopy Society.

Development, Implementation, and Use of a Process to Promote Knowledge Translation in Rehabilitation.

PubMed

Moore, Jennifer L; Carpenter, Julia; Doyle, Anne Marie; Doyle, Laura; Hansen, Piper; Hahn, Bridget; Hornby, T George; Roth, Heidi R; Spoeri, Susan; Tappan, Rachel; Van Der Laan, Krista

2018-01-01

To examine the use and effect of the Battery of Rehabilitation Assessments and Interventions on evidence-based practice (EBP) over 6 years. Successive independent samples study. Large rehabilitation system. Successive samples of allied health clinicians (N=372) in 2009 (n=136), 2012 (n=115), and 2015 (n=121). The Battery of Rehabilitation Assessments and Interventions includes 2 components: (1) a process to synthesize, adapt, and make recommendations about the application of evidence; and (2) a process to implement the recommended practices in 3 levels of care. To assess the effect of the project, surveys on EBP perspectives, use, and barriers were conducted before Battery of Rehabilitation Assessments and Interventions implementation and 3 and 6 years after implementation. Questions about effect of the project on clinical practice were included 3 and 6 years postimplementation. Survey data indicate the Battery of Rehabilitation Assessments and Interventions resulted in a significant increase in use of EBPs to make clinical decisions and justify care. As a result of the project, survey participants reported a substantial increase in use of outcome measures in 2012 (74%) and 2015 (91%) and evidence-based interventions in 2012 (62%) and 2015 (82%). In 2012, significant differences (P≤.01) in effect of the Battery of Rehabilitation Assessments and Interventions on practice were identified between therapists who were directly involved in the project and Interventions compared with uninvolved therapists. In 2015, no significant differences existed between involved and uninvolved therapists. After 6 years of sustained implementation efforts, the Battery of Rehabilitation Assessments and Interventions expedited the adoption of EBPs throughout a large system of care in rehabilitation. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Clinical consequences of diet-induced dysbiosis.

PubMed

Chan, Yee Kwan; Estaki, Mehrbod; Gibson, Deanna L

2013-01-01

Various disease states are associated with an imbalance of protective and pathogenic bacteria in the gut, termed dysbiosis. Current evidence reveals that dietary factors affect the microbial ecosystem in the gut. Changes to community structure of the intestinal microbiota are not without consequence considering the wide effects that the microbes have on both local and systemic immunity. The goal of this review is to give insight into the importance of gut microbiota in disease development and the possible therapeutic interventions in clinical settings. We introduce the complex tripartite relationship between diet, microbes and the gut epithelium. This is followed by a summary of clinical evidence of diet-induced dysbiosis as a contributing factor in the development of gastrointestinal diseases like inflammatory bowel disease, irritable bowel syndrome and colorectal cancer, as well as systemic diseases like obesity, diabetes, atherosclerosis and nonalcoholic fatty liver disease. Finally, the current dietary and microbial interventions to promote a healthy microbial profile will be reviewed. © 2013 S. Karger AG, Basel.

Pediatric Psychologist Use of Adherence Assessments and Interventions

PubMed Central

Rohan, Jennifer M.; Martin, Staci; Hommel, Kevin; Greenley, Rachel Neff; Loiselle, Kristin; Ambrosino, Jodie; Fredericks, Emily M.

2013-01-01

Objective To document current clinical practices for medical regimen adherence assessment and intervention in the field of pediatric psychology. Methods 113 members of the Society of Pediatric Psychology completed an anonymous online survey that assessed use of adherence assessments and interventions in clinical practice, barriers and facilitators to their use, and preferred resources for obtaining information on adherence assessments and interventions. Results Respondents reported using a range of adherence assessment and intervention strategies, some of which are evidence-based. Barriers to implementing these clinical strategies included time constraints and lack of familiarity with available clinical tools. Respondents reported that education about effective clinical tools would facilitate their use of adherence assessments and interventions. Conclusions Future research and clinical efforts in adherence should consider developing practical tools for clinical practice, making accessible resources to promote dissemination of these tools, and increase understanding of clinician implementation of adherence assessments and interventions. PMID:23658375

Using Evidence-Based Internet Interventions to Reduce Health Disparities Worldwide

PubMed Central

2010-01-01

Health disparities are a persistent problem worldwide. A major obstacle to reducing health disparities is reliance on “consumable interventions,” that is, interventions that, once used, cannot be used again. To reduce health disparities, interventions are required that can be used again and again without losing their therapeutic power, that can reach people even if local health care systems do not provide them with needed health care, and that can be shared globally without taking resources away from the populations where the interventions were developed. This paper presents the argument that automated self-help evidence-based Internet interventions meet the above criteria and can contribute to the reduction of health disparities worldwide. Proof-of-concept studies show that evidence-based Internet interventions can reach hundreds of thousands of people worldwide and could be used in public sector settings to augment existing offerings and provide services not currently available (such as prevention interventions). This paper presents a framework for systematically filling in a matrix composed of columns representing common health problems and rows representing languages. To bring the benefits of evidence-based Internet interventions to the underserved, public sector clinics should establish eHealth resource centers, through which patients could be screened online for common disorders and provided with evidence-based Internet intervention services not currently available at the clinics. These resources should be available in the patients’ languages, in formats that do not require literacy, and that can be accessed with mobile devices. Such evidence-based Internet interventions should then be shared with public sector clinics as well as individuals anywhere in the world. Finally, this paper addresses sustainability and describes a continuum of evidence-based Internet interventions to share nationally and across the world. This approach to expanding health service delivery will significantly contribute to a reduction of health disparities worldwide, adding to the often-quoted slogan, “Think globally, act locally,” a third line: “Share globally.” PMID:21169162

Using evidence-based internet interventions to reduce health disparities worldwide.

PubMed

Muñoz, Ricardo F

2010-12-17

Health disparities are a persistent problem worldwide. A major obstacle to reducing health disparities is reliance on "consumable interventions," that is, interventions that, once used, cannot be used again. To reduce health disparities, interventions are required that can be used again and again without losing their therapeutic power, that can reach people even if local health care systems do not provide them with needed health care, and that can be shared globally without taking resources away from the populations where the interventions were developed. This paper presents the argument that automated self-help evidence-based Internet interventions meet the above criteria and can contribute to the reduction of health disparities worldwide. Proof-of-concept studies show that evidence-based Internet interventions can reach hundreds of thousands of people worldwide and could be used in public sector settings to augment existing offerings and provide services not currently available (such as prevention interventions). This paper presents a framework for systematically filling in a matrix composed of columns representing common health problems and rows representing languages. To bring the benefits of evidence-based Internet interventions to the underserved, public sector clinics should establish eHealth resource centers, through which patients could be screened online for common disorders and provided with evidence-based Internet intervention services not currently available at the clinics. These resources should be available in the patients' languages, in formats that do not require literacy, and that can be accessed with mobile devices. Such evidence-based Internet interventions should then be shared with public sector clinics as well as individuals anywhere in the world. Finally, this paper addresses sustainability and describes a continuum of evidence-based Internet interventions to share nationally and across the world. This approach to expanding health service delivery will significantly contribute to a reduction of health disparities worldwide, adding to the often-quoted slogan, "Think globally, act locally," a third line: "Share globally."

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes.

PubMed

Lasiter, Sue; Oles, Sylwia K; Mundell, James; London, Susan; Khan, Babar

2016-01-01

The purpose of this scoping review is to identify evidence describing benefits of interventions provided in intensive care unit (ICU) survivor follow-up clinics. Advances in ICU treatments have increased the number of survivors who require specialized care for ICU-related sequelae. Intensive care unit survivor follow-up clinics exist, yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken. Ten databases were searched yielding 111 relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding nonrelated publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes. Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms, whereas evidence to support implementation of other interventions was weak. Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored. Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

An exploration of clinical interventions provided by pharmacists within a complex asthma service.

PubMed

Lemay, Kate S; Saini, Bandana; Bosnic-Anticevich, Sinthia; Smith, Lorraine; Stewart, Kay; Emmerton, Lynne; Burton, Deborah L; Krass, Ines; Armour, Carol L

2015-01-01

Pharmacists in Australia are accessible health care professionals, and their provision of clinical pharmacy interventions in a range of areas has been proven to improve patient outcomes. Individual clinical pharmacy interventions in the area of asthma management have been very successful. An understanding of the nature of these interventions will inform future pharmacy services. What we do not know is when pharmacists provide a complex asthma service, what elements of that service (interventions) they choose to deliver. To explore the scope and frequency of asthma-related clinical interventions provided by pharmacists to patients in an evidence-based complex asthma service. Pharmacists from 4 states/territories of Australia were trained in asthma management. People with asthma had 3 or 4 visits to the pharmacy. Guided by a structured patient file, the pharmacist assessed the patient's asthma and management and provided interventions where and when considered appropriate, based on their clinical decision making skills. The interventions were recorded in a checklist in the patient file. They were then analysed descriptively and thematically. Pharmacists provided 22,909 clinical pharmacy interventions over the service to 570 patients (398 of whom completed the service). The most frequently delivered interventions were in the themes 'Education on asthma', 'Addressing trigger factors', 'Medications - safe and effective use' and 'Explore patient perspectives'. The patients had a high and ongoing need for interventions. Pharmacists selected interventions based on their assessment of perceived need then revisited and reinforced these interventions. Pharmacists identified a number of areas in which patients required interventions to assist with their asthma management. Many of these were perceived to require continuing reinforcement over the duration of the service. Pharmacists were able to use their clinical judgement to assess patients and provide clinical pharmacy interventions across a range of asthma management needs.

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

PubMed

Berner, Eta S; Houston, Thomas K; Ray, Midge N; Allison, Jeroan J; Heudebert, Gustavo R; Chatham, W Winn; Kennedy, John I; Glandon, Gerald L; Norton, Patricia A; Crawford, Myra A; Maisiak, Richard S

2006-01-01

To evaluate the effectiveness of a personal digital assistant (PDA)-based clinical decision support system (CDSS) on nonsteroidal anti-inflammatory drug (NSAID) prescribing safety in the outpatient setting. The design was a randomized, controlled trial conducted in a university-based resident clinic. Internal medicine residents received a PDA-based CDSS suite. For intervention residents, the CDSS included a prediction rule for NSAID-related gastrointestinal risk assessment and treatment recommendations. Unannounced standardized patients (SPs) trained to portray musculoskeletal symptoms presented to study physicians. Safety outcomes were assessed from the prescriptions given to the SPs. Each prescription was reviewed by a committee of clinicians blinded to participant, intervention group assignment, and baseline or follow-up status. Prescriptions were judged as safe or unsafe. The main outcome measure was the differential change in unsafe prescribing of NSAIDs for the intervention versus the control group. At baseline, the mean proportion of cases per physician with unsafe prescriptions for the two groups was similar (0.27 vs. 0.29, p > 0.05). Controlling for baseline performance, intervention participants prescribed more safely than controls after receiving the CDSS (0.23 vs. 0.45 [F = 4.24, p < 0.05]). With the CDSS, intervention participants documented more complete assessment of patient gastrointestinal risk from NSAIDs. PARTICIPANTS provided with a PDA-based CDSS for NSAID prescribing made fewer unsafe treatment decisions than participants without the CDSS.

An Interrupted Time Series Analysis to Determine the Effect of an Electronic Health Record-Based Intervention on Appropriate Screening for Type 2 Diabetes in Urban Primary Care Clinics in New York City.

PubMed

Albu, Jeanine B; Sohler, Nancy; Li, Rui; Li, Xuan; Young, Edwin; Gregg, Edward W; Ross-Degnan, Dennis

2017-08-01

To determine the impact of a health system-wide primary care diabetes management system, which included targeted guidelines for type 2 diabetes (T2DM) and prediabetes (dysglycemia) screening, on detection of previously undiagnosed dysglycemia cases. Intervention included electronic health record (EHR)-based decision support and standardized providers and staff training for using the American Diabetes Association guidelines for dysglycemia screening. Using EHR data, we identified 40,456 adults without T2DM or recent screening with a face-to-face visit (March 2011-December 2013) in five urban clinics. Interrupted time series analyses examined the impact of the intervention on trends in three outcomes: 1 ) monthly proportion of eligible patients receiving dysglycemia testing, 2 ) two negative comparison conditions (dysglycemia testing among ineligible patients and cholesterol screening), and 3 ) yield of undiagnosed dysglycemia among those tested. Baseline monthly proportion of eligible patients receiving testing was 7.4-10.4%. After the intervention, screening doubled (mean increase + 11.0% [95% CI 9.0, 13.0], proportion range 18.6-25.3%). The proportion of ineligible patients tested also increased (+5.0% [95% CI 3.0, 8.0]) with no concurrent change in cholesterol testing (+0% [95% CI -0.02, 0.05]). About 59% of test results in eligible patients showed dysglycemia both before and after the intervention. Implementation of a policy for systematic dysglycemia screening including formal training and EHR templates in urban academic primary care clinics resulted in a doubling of appropriate testing and the number of patients who could be targeted for treatment to prevent or delay T2DM. © 2017 by the American Diabetes Association.

A cluster randomized trial of a transition intervention for adolescents with congenital heart disease: rationale and design of the CHAPTER 2 study.

PubMed

Mackie, Andrew S; Rempel, Gwen R; Kovacs, Adrienne H; Kaufman, Miriam; Rankin, Kathryn N; Jelen, Ahlexxi; Manlhiot, Cedric; Anthony, Samantha J; Magill-Evans, Joyce; Nicholas, David; Sananes, Renee; Oechslin, Erwin; Dragieva, Dimi; Mustafa, Sonila; Williams, Elina; Schuh, Michelle; McCrindle, Brian W

2016-06-06

The population of adolescents and young adults with congenital heart disease (CHD) is growing exponentially. These survivors are at risk of late cardiac complications and require lifelong cardiology care. However, there is a paucity of data on how to prepare adolescents to assume responsibility for their health and function within the adult health care system. Evidence-based transition strategies are required. The Congenital Heart Adolescents Participating in Transition Evaluation Research (CHAPTER 2) Study is a two-site cluster randomized clinical trial designed to evaluate the efficacy of a nurse-led transition intervention for 16-17 year olds with moderate or complex CHD. The primary endpoint is excess time to adult CHD care, defined as the time interval between the final pediatric cardiology appointment and the first adult CHD appointment, minus the recommended time interval between these appointments. Secondary endpoints include the MyHeart score (CHD knowledge), Transition Readiness Assessment Questionnaire score, and need for catheter or surgical re-intervention. Participants are enrolled in clusters based on week of attendance in the pediatric cardiology clinic. The intervention consists of two one-hour individualized sessions between a cardiology nurse and study participant. Session One focuses on knowledge of the participant's CHD, review of their cardiac anatomy and prior interventions, and potential late cardiac complications. Session Two focuses on self-management and communication skills through review and discussion of videos and role-play. The study will recruit 120 participants. Many adolescents and young adults experience a gap in care predisposing them to late cardiac complications. The CHAPTER 2 Study will investigate the impact of a nurse-led transition intervention among adolescents with CHD. Fidelity of the intervention is a major focus and priority. This study will build on our experience by (i) enrolling at two tertiary care programs, (ii) including a self-management intervention component, and (iii) evaluating the impact of the intervention on time to ACHD care, a clinically relevant outcome. The results of this study will inform pediatric cardiology programs, patients and policy makers in judging whether a structured intervention program provides clinically meaningful outcomes for adolescents and young adults living with CHD. ClinicalTrials.gov ID NCT01723332.

Healthcare system responses to intimate partner violence in low and middle-income countries: evidence is growing and the challenges become clearer.

PubMed

Taft, Angela; Colombini, Manuela

2017-07-12

The damage to health caused by intimate partner violence demands effective responses from healthcare providers and healthcare systems worldwide. To date, most evidence for the few existing, effective interventions in use comes from high-income countries. Gupta et al. provide rare evidence of a nurse-delivered intimate partner violence screening, supportive care and referral intervention from a large-scale randomised trial in Mexican public health clinics. No difference was found in the primary outcome of reduction in intimate partner violence. There were significant short-term benefits in safety planning and mental health (secondary outcomes) for women in the intervention arm, but these were not sustained.This important study highlights the challenges of primary outcome choices in such studies, and further challenges for the sustainability of healthcare systems and healthcare provider interventions. These challenges include the role of theory for sustainability and the risk that baseline measures of intimate partner violence can wash out intervention effects. We emphasise the importance of studying the processes of adaptation, integration and coordination in the context of the wider healthcare system.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0880-y.

The Green, Amber, Red Delineation of Risk and Need (GARDIAN) management system: a pragmatic approach to optimizing heart health from primary prevention to chronic disease management.

PubMed

Carrington, Melinda J; Kok, Simone; Jansen, Kiki; Stewart, Simon

2013-08-01

A sustained epidemic of cardiovascular disease and related risk factors is a global phenomenon contributing significantly to premature deaths and costly morbidity. Preventative strategies across the full continuum of life, from a population to individual perspective, are not optimally applied. This paper describes a simple and adaptable 'traffic-light' system we have developed to systematically perform individual risk and need delineation in order to 'titrate' the intensity and frequency of healthcare intervention in a cost-effective manner. The GARDIAN (Green Amber Red Delineation of Risk and Need) system is an individual assessment of risk and need that modulates the frequency and intensity of future healthcare intervention. Individual assessment of risk and need for ongoing intervention and support is determined with reference to three domains: (1) clinical stability, (2) gold-standard management, and (3) a broader, holistic assessment of individual circumstance. This can be applied from a primary prevention, secondary prevention, or chronic disease management perspective. Our experience with applying and validating GARDIAN to titrate healthcare resources according to need has been extensive to date, with >5000 individuals profiled in a host of clinical settings. A series of clinical randomized trials will determine the impact of the GARDIAN system on important indices of healthcare utilization and health status. The GARDIAN model to delineating risk and need for varied intensity of management shows strong potential to cost effectively improve health outcomes for both individuals at risk of heart disease and those with established heart disease.

Pediatric interventional radiology clinic - how are we doing?

PubMed

Rubenstein, Jonathan; Zettel, Julie C; Lee, Eric; Cote, Michelle; Aziza, Albert; Connolly, Bairbre L

2016-07-01

Development of a pediatric interventional radiology clinic is a necessary component of providing a pediatric interventional radiology service. Patient satisfaction is important when providing efficient, high-quality care. To analyze the care provided by a pediatric interventional radiology clinic from the perspective of efficiency and parent satisfaction, so as to identify areas for improvement. The prospective study was both quantitative and qualitative. The quantitative component measured clinic efficiency (waiting times, duration of clinic visit, nurse/physician time allocation and assessments performed; n = 91). The qualitative component assessed parental satisfaction with their experience with the pediatric interventional radiology clinic, using a questionnaire (5-point Likert scale) and optional free text section for feedback (n = 80). Questions explored the family's perception of relevance of information provided, consent process and overall satisfaction with their pediatric interventional radiology clinic experience. Families waited a mean of 11 and 10 min to meet the physician and nurse, respectively. Nurses and physicians spent a mean of 28 and 21 min with the families, respectively. The average duration of the pediatric interventional radiology clinic consultation was 56 min. Of 80 survey participants, 83% were satisfied with their experience and 94% said they believed providing consent before the day of the procedure was helpful. Only 5% of respondents were not satisfied with the time-efficiency of the interventional radiology clinic. Results show the majority of patients/parents are very satisfied with the pediatric interventional radiology clinic visit. The efficiency of the pediatric interventional radiology clinic is satisfactory; however, adherence to stricter scheduling can be improved.

Access to care for patients with time-sensitive conditions in Pennsylvania.

PubMed

Salhi, Rama A; Edwards, J Matthew; Gaieski, David F; Band, Roger A; Abella, Benjamin S; Carr, Brendan G

2014-05-01

Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals. All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles. The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes. Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Impact of National Institutes of Health Gastrointestinal PROMIS Measures in Clinical Practice: Results of a Multicenter Controlled Trial.

PubMed

Almario, Christopher V; Chey, William D; Khanna, Dinesh; Mosadeghi, Sasan; Ahmed, Shahzad; Afghani, Elham; Whitman, Cynthia; Fuller, Garth; Reid, Mark; Bolus, Roger; Dennis, Buddy; Encarnacion, Rey; Martinez, Bibiana; Soares, Jennifer; Modi, Rushaba; Agarwal, Nikhil; Lee, Aaron; Kubomoto, Scott; Sharma, Gobind; Bolus, Sally; Spiegel, Brennan M R

2016-11-01

The National Institutes of Health (NIH) created the Patient Reported Outcomes Measurement Information System (PROMIS) to allow efficient, online measurement of patient-reported outcomes (PROs), but it remains untested whether PROMIS improves outcomes. Here, we aimed to compare the impact of gastrointestinal (GI) PROMIS measures vs. usual care on patient outcomes. We performed a pragmatic clinical trial with an off-on study design alternating weekly between intervention (GI PROMIS) and control arms at one Veterans Affairs and three university-affiliated specialty clinics. Adults with GI symptoms were eligible. Intervention patients completed GI PROMIS symptom questionnaires on an e-portal 1 week before their visit; PROs were available for review by patients and their providers before and during the clinic visit. Usual care patients were managed according to customary practices. Our primary outcome was patient satisfaction as determined by the Consumer Assessment of Healthcare Providers and Systems questionnaire. Secondary outcomes included provider interpersonal skills (Doctors' Interpersonal Skills Questionnaire (DISQ)) and shared decision-making (9-item Shared Decision Making Questionnaire (SDM-Q-9)). There were 217 and 154 patients in the GI PROMIS and control arms, respectively. Patient satisfaction was similar between groups (P>0.05). Intervention patients had similar assessments of their providers' interpersonal skills (DISQ 89.4±11.7 vs. 89.8±16.0, P=0.79) and shared decision-making (SDM-Q-9 79.3±12.4 vs. 79.0±22.0, P=0.85) vs. This is the first controlled trial examining the impact of NIH PROMIS in clinical practice. One-time use of GI PROMIS did not improve patient satisfaction or assessment of provider interpersonal skills and shared decision-making. Future studies examining how to optimize PROs in clinical practice are encouraged before widespread adoption.

DianaHealth.com, an On-Line Database Containing Appraisals of the Clinical Value and Appropriateness of Healthcare Interventions: Database Development and Retrospective Analysis.

PubMed

Bonfill, Xavier; Osorio, Dimelza; Solà, Ivan; Pijoan, Jose Ignacio; Balasso, Valentina; Quintana, Maria Jesús; Puig, Teresa; Bolibar, Ignasi; Urrútia, Gerard; Zamora, Javier; Emparanza, José Ignacio; Gómez de la Cámara, Agustín; Ferreira-González, Ignacio

2016-01-01

To describe the development of a novel on-line database aimed to serve as a source of information concerning healthcare interventions appraised for their clinical value and appropriateness by several initiatives worldwide, and to present a retrospective analysis of the appraisals already included in the database. Database development and a retrospective analysis. The database DianaHealth.com is already on-line and it is regularly updated, independent, open access and available in English and Spanish. Initiatives are identified in medical news, in article references, and by contacting experts in the field. We include appraisals in the form of clinical recommendations, expert analyses, conclusions from systematic reviews, and original research that label any health care intervention as low-value or inappropriate. We obtain the information necessary to classify the appraisals according to type of intervention, specialties involved, publication year, authoring initiative, and key words. The database is accessible through a search engine which retrieves a list of appraisals and a link to the website where they were published. DianaHealth.com also provides a brief description of the initiatives and a section where users can report new appraisals or suggest new initiatives. From January 2014 to July 2015, the on-line database included 2940 appraisals from 22 initiatives: eleven campaigns gathering clinical recommendations from scientific societies, five sets of conclusions from literature review, three sets of recommendations from guidelines, two collections of articles on low clinical value in medical journals, and an initiative of our own. We have developed an open access on-line database of appraisals about healthcare interventions considered of low clinical value or inappropriate. DianaHealth.com could help physicians and other stakeholders make better decisions concerning patient care and healthcare systems sustainability. Future efforts should be focused on assessing the impact of these appraisals in the clinical practice.

DianaHealth.com, an On-Line Database Containing Appraisals of the Clinical Value and Appropriateness of Healthcare Interventions: Database Development and Retrospective Analysis

PubMed Central

Bonfill, Xavier; Osorio, Dimelza; Solà, Ivan; Pijoan, Jose Ignacio; Balasso, Valentina; Quintana, Maria Jesús; Puig, Teresa; Bolibar, Ignasi; Urrútia, Gerard; Zamora, Javier; Emparanza, José Ignacio; Gómez de la Cámara, Agustín; Ferreira-González, Ignacio

2016-01-01

Objective To describe the development of a novel on-line database aimed to serve as a source of information concerning healthcare interventions appraised for their clinical value and appropriateness by several initiatives worldwide, and to present a retrospective analysis of the appraisals already included in the database. Methods and Findings Database development and a retrospective analysis. The database DianaHealth.com is already on-line and it is regularly updated, independent, open access and available in English and Spanish. Initiatives are identified in medical news, in article references, and by contacting experts in the field. We include appraisals in the form of clinical recommendations, expert analyses, conclusions from systematic reviews, and original research that label any health care intervention as low-value or inappropriate. We obtain the information necessary to classify the appraisals according to type of intervention, specialties involved, publication year, authoring initiative, and key words. The database is accessible through a search engine which retrieves a list of appraisals and a link to the website where they were published. DianaHealth.com also provides a brief description of the initiatives and a section where users can report new appraisals or suggest new initiatives. From January 2014 to July 2015, the on-line database included 2940 appraisals from 22 initiatives: eleven campaigns gathering clinical recommendations from scientific societies, five sets of conclusions from literature review, three sets of recommendations from guidelines, two collections of articles on low clinical value in medical journals, and an initiative of our own. Conclusions We have developed an open access on-line database of appraisals about healthcare interventions considered of low clinical value or inappropriate. DianaHealth.com could help physicians and other stakeholders make better decisions concerning patient care and healthcare systems sustainability. Future efforts should be focused on assessing the impact of these appraisals in the clinical practice. PMID:26840451

Clinical and Neurobiological Perspectives of Empowering Pediatric Cancer Patients Using Videogames

PubMed Central

Govender, Meveshni; Bowen, Randy C.; German, Massiell L.; Bulaj, Grzegorz

2015-01-01

Abstract Pediatric oncology patients often experience fatigue and physical and mental deconditioning during and following chemotherapy treatments, contributing to diminished quality of life. Patient empowerment is a core principle of patient-centered care and reflects one's ability to positively affect his or her own health behavior and health status. Empowerment interventions may enhance patients' internal locus of control, resilience, coping skills, and self-management of symptoms related to disease and therapy. Clinical and technological advancements in therapeutic videogames and mobile medical applications (mobile health) can facilitate delivery of the empowerment interventions for medical purposes. This review summarizes clinical strategies for empowering pediatric cancer patients, as well as their relationship with developing a “fighting spirit” in physical and mental health. To better understand physiological aspects of empowerment and to elucidate videogame-based intervention strategies, brain neuronal circuits and neurotransmitters during stress, fear, and resilience are also discussed. Neuroimaging studies point to the role of the reward system pathways in resilience and empowerment in patients. Taken together, videogames and mobile health applications open translational research opportunities to develop and deliver empowerment interventions to pediatric cancer patients and also to those with other chronic diseases. PMID:26287927

Clinical and Neurobiological Perspectives of Empowering Pediatric Cancer Patients Using Videogames.

PubMed

Govender, Meveshni; Bowen, Randy C; German, Massiell L; Bulaj, Grzegorz; Bruggers, Carol S

2015-10-01

Pediatric oncology patients often experience fatigue and physical and mental deconditioning during and following chemotherapy treatments, contributing to diminished quality of life. Patient empowerment is a core principle of patient-centered care and reflects one's ability to positively affect his or her own health behavior and health status. Empowerment interventions may enhance patients' internal locus of control, resilience, coping skills, and self-management of symptoms related to disease and therapy. Clinical and technological advancements in therapeutic videogames and mobile medical applications (mobile health) can facilitate delivery of the empowerment interventions for medical purposes. This review summarizes clinical strategies for empowering pediatric cancer patients, as well as their relationship with developing a "fighting spirit" in physical and mental health. To better understand physiological aspects of empowerment and to elucidate videogame-based intervention strategies, brain neuronal circuits and neurotransmitters during stress, fear, and resilience are also discussed. Neuroimaging studies point to the role of the reward system pathways in resilience and empowerment in patients. Taken together, videogames and mobile health applications open translational research opportunities to develop and deliver empowerment interventions to pediatric cancer patients and also to those with other chronic diseases.

Drug-related problems: evaluation of a classification system in the daily practice of a Swiss University Hospital.

PubMed

Lampert, Markus L; Kraehenbuehl, Stephan; Hug, Balthasar L

2008-12-01

To evaluate the Pharmaceutical Care Network Europe (PCNE) classification system as a tool for documenting the impact of a hospital clinical pharmacology service. Two medical wards comprising totally 85 beds in a university hospital. Number of events classified with the PCNE-system, their acceptance by the medical staff and cost implications. Clinical pharmacy review of pharmacotherapy on ward rounds and from case notes were documented, and identified drug-related problems (DRPs) were classified using the PCNE system version 5.00. During 70 observation days 216 interventions were registered of which 213 (98.6%) could be classified: 128 (60.1%) were detected by reviewing the case notes, 33 (15.5%) on ward rounds, 32 (15.0%) by direct reporting to the clinical pharmacist (CP), and 20 (9.4%) on non-formulary prescriptions. Of 148 suggested interventions by the CP 123 (83.0%) were approved by the responsible physician, 12 ADR reports (8.1%) were submitted to the local pharmacovigilance centre and 31 (20.9%) specific information given without further need for action. An evaluation of the DRPs showed that direct drug costs of 2,058 within the study period or 10,731 per year could be avoided. We consider the PCNE system to be a practical tool in the hospital setting, which demonstrates the values of a clinical pharmacy service in terms of identifying and reducing DRPs and also has the potential to reduce prescribing costs.

A gesture-controlled projection display for CT-guided interventions.

PubMed

Mewes, A; Saalfeld, P; Riabikin, O; Skalej, M; Hansen, C

2016-01-01

The interaction with interventional imaging systems within a sterile environment is a challenging task for physicians. Direct physician-machine interaction during an intervention is rather limited because of sterility and workspace restrictions. We present a gesture-controlled projection display that enables a direct and natural physician-machine interaction during computed tomography (CT)-based interventions. Therefore, a graphical user interface is projected on a radiation shield located in front of the physician. Hand gestures in front of this display are captured and classified using a leap motion controller. We propose a gesture set to control basic functions of intervention software such as gestures for 2D image exploration, 3D object manipulation and selection. Our methods were evaluated in a clinically oriented user study with 12 participants. The results of the performed user study confirm that the display and the underlying interaction concept are accepted by clinical users. The recognition of the gestures is robust, although there is potential for improvements. The gesture training times are less than 10 min, but vary heavily between the participants of the study. The developed gestures are connected logically to the intervention software and intuitive to use. The proposed gesture-controlled projection display counters current thinking, namely it gives the radiologist complete control of the intervention software. It opens new possibilities for direct physician-machine interaction during CT-based interventions and is well suited to become an integral part of future interventional suites.

Description of interventions is under-reported in physical therapy clinical trials.

PubMed

Hariohm, K; Jeyanthi, S; Kumar, J Saravan; Prakash, V

Amongst several barriers to the application of quality clinical evidence and clinical guidelines into routine daily practice, poor description of interventions reported in clinical trials has received less attention. Although some studies have investigated the completeness of descriptions of non-pharmacological interventions in randomized trials, studies that exclusively analyzed physical therapy interventions reported in published trials are scarce. To evaluate the quality of descriptions of interventions in both experimental and control groups in randomized controlled trials published in four core physical therapy journals. We included all randomized controlled trials published from the Physical Therapy Journal, Journal of Physiotherapy, Clinical Rehabilitation, and Archives of Physical Medicine and Rehabilitation between June 2012 and December 2013. Each randomized controlled trial (RCT) was analyzed and coded for description of interventions using the checklist developed by Schroter et al. Out of 100 RCTs selected, only 35 RCTs (35%) fully described the interventions in both the intervention and control groups. Control group interventions were poorly described in the remaining RCTs (65%). Interventions, especially in the control group, are poorly described in the clinical trials published in leading physical therapy journals. A complete description of the intervention in a published report is crucial for physical therapists to be able to use the intervention in clinical practice. Copyright © 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.

Evaluation of a web based informatics system with data mining tools for predicting outcomes with quantitative imaging features in stroke rehabilitation clinical trials

NASA Astrophysics Data System (ADS)

Wang, Ximing; Kim, Bokkyu; Park, Ji Hoon; Wang, Erik; Forsyth, Sydney; Lim, Cody; Ravi, Ragini; Karibyan, Sarkis; Sanchez, Alexander; Liu, Brent

2017-03-01

Quantitative imaging biomarkers are used widely in clinical trials for tracking and evaluation of medical interventions. Previously, we have presented a web based informatics system utilizing quantitative imaging features for predicting outcomes in stroke rehabilitation clinical trials. The system integrates imaging features extraction tools and a web-based statistical analysis tool. The tools include a generalized linear mixed model(GLMM) that can investigate potential significance and correlation based on features extracted from clinical data and quantitative biomarkers. The imaging features extraction tools allow the user to collect imaging features and the GLMM module allows the user to select clinical data and imaging features such as stroke lesion characteristics from the database as regressors and regressands. This paper discusses the application scenario and evaluation results of the system in a stroke rehabilitation clinical trial. The system was utilized to manage clinical data and extract imaging biomarkers including stroke lesion volume, location and ventricle/brain ratio. The GLMM module was validated and the efficiency of data analysis was also evaluated.

Developing Medications Targeting Glutamatergic Dysfunction in Autism: Progress to Date

PubMed Central

Fung, Lawrence K.; Hardan, Antonio Y.

2015-01-01

Pharmacologic treatments targeting specific molecular mechanisms relevant for autism spectrum disorder (ASD) are beginning to emerge in early drug development. This article reviews the evidence for the disruption of glutamatergic neurotransmission in animal models of social deficits and summarizes key pre-clinical and clinical efforts in developing pharmacologic interventions based on modulation of glutamatergic systems in individuals with ASD. Understanding the pathobiology of the glutamatergic system has led to the development of new investigational treatments for individuals with ASD. Specific examples of medications that modulate the glutamatergic system in preclinical and clinical studies are described. Finally, we will discuss the limitations of current strategies and future opportunities in developing medications targeting the glutamatergic system for treating individuals with ASD. PMID:26104862

Randomized Trial of Intelligent Sensor System for Early Illness Alerts in Senior Housing.

PubMed

Rantz, Marilyn; Phillips, Lorraine J; Galambos, Colleen; Lane, Kari; Alexander, Gregory L; Despins, Laurel; Koopman, Richelle J; Skubic, Marjorie; Hicks, Lanis; Miller, Steven; Craver, Andy; Harris, Bradford H; Deroche, Chelsea B

2017-10-01

Measure the clinical effectiveness and cost effectiveness of using sensor data from an environmentally embedded sensor system for early illness recognition. This sensor system has demonstrated in pilot studies to detect changes in function and in chronic diseases or acute illnesses on average 10 days to 2 weeks before usual assessment methods or self-reports of illness. Prospective intervention study in 13 assisted living (AL) communities of 171 residents randomly assigned to intervention (n=86) or comparison group (n=85) receiving usual care. Intervention participants lived with the sensor system an average of one year. Continuous data collected 24 hours/7 days a week from motion sensors to measure overall activity, an under mattress bed sensor to capture respiration, pulse, and restlessness as people sleep, and a gait sensor that continuously measures gait speed, stride length and time, and automatically assess for increasing fall risk as the person walks around the apartment. Continuously running computer algorithms are applied to the sensor data and send health alerts to staff when there are changes in sensor data patterns. The randomized comparison group functionally declined more rapidly than the intervention group. Walking speed and several measures from GaitRite, velocity, step length left and right, stride length left and right, and the fall risk measure of functional ambulation profile (FAP) all had clinically significant changes. The walking speed increase (worse) and velocity decline (worse) of 0.073 m/s for comparison group exceeded 0.05 m/s, a value considered to be a minimum clinically important difference. No differences were measured in health care costs. These findings demonstrate that sensor data with health alerts and fall alerts sent to AL nursing staff can be an effective strategy to detect and intervene in early signs of illness or functional decline. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Effect of an obesity best practice alert on physician documentation and referral practices.

PubMed

Fitzpatrick, Stephanie L; Dickins, Kirsten; Avery, Elizabeth; Ventrelle, Jennifer; Shultz, Aaron; Kishen, Ekta; Rothschild, Steven

2017-12-01

The Centers for Medicare & Medicaid Services Electronic Health Record Meaningful Use Incentive Program requires physicians to document body mass index (BMI) and a follow-up treatment plan for adult patients with BMI ≥ 25. To examine the effect of a best practice alert on physician documentation of obesity-related care and referrals to weight management treatment, in a cluster-randomized design, 14 primary care clinics at an academic medical center were randomized to best practice alert intervention (n = 7) or comparator (n = 7). The alert was triggered when both height and weight were entered and BMI was ≥30. Both intervention and comparator clinics could document meaningful use by selecting a nutrition education handout within the alert. Intervention clinics could also select a referral option from the list of clinic and community-based weight management programs embedded in the alert. Main outcomes were proportion of eligible patients with (1) obesity-related documentation and (2) referral. There were 26,471 total primary care encounters with 12,981 unique adult patients with BMI ≥ 30 during the 6-month study period. Documentation doubled (17 to 33%) with implementation of the alert. However, intervention clinics were not significantly more likely to refer patients to weight management than comparator clinics (2.8 vs. 1.3%, p = 0.07). Although the alert was associated with increased physician meaningful use compliance, it was not an effective strategy for improving patient access to weight management services. Further research is needed to understand system-level characteristics that influence obesity management in primary care.

Time motion analysis of nursing work in ICU, telemetry and medical-surgical units.

PubMed

Schenk, Elizabeth; Schleyer, Ruth; Jones, Cami R; Fincham, Sarah; Daratha, Kenn B; Monsen, Karen A

2017-11-01

This study examined nurses' work, comparing nursing interventions and locations across three units in a United States hospital using Omaha System standardized terminology as the organizing framework. The differences in nurses' acute-care work across unit types are not well understood. Prior investigators have used time-motion methodologies; few have compared differences across units, nor used standardized terminology. Nurse-observers recorded locations and interventions of nurses on three acute-care units using hand-held devices and web-based TimeCaT ™ software. Nursing interventions were mapped to Omaha System terms. Unit-differences were analysed. Nurses changed locations approximately every 2 min, and averaged approximately one intervention/minute. Unit differences were found in both the interventions performed and the locations. Most interventions were case-management related, demonstrating the nurses' patient management/coordination role. Unit differences in nursing interventions and location were found among three unit types. Omaha System terminology, as well as the observational method used, were found to be feasible and practical. Nursing work varies by unit, yet managers have not been armed with empirical data with which to make more informed decisions about nurses' work priorities, clinical outcomes, patient satisfaction, staff satisfaction and cost. The results from this study will help them to do so. © 2017 John Wiley & Sons Ltd.

Designing healthcare information technology to catalyse change in clinical care.

PubMed

Lester, William T; Zai, Adrian H; Grant, Richard W; Chueh, Henry C

2008-01-01

The gap between best practice and actual patient care continues to be a pervasive problem in our healthcare system. Efforts to improve on this knowledge-performance gap have included computerised disease management programs designed to improve guideline adherence. However, current computerised reminder and decision support interventions directed at changing physician behaviour have had only a limited and variable effect on clinical outcomes. Further, immediate pay-for-performance financial pressures on institutions have created an environment where disease management systems are often created under duress, appended to existing clinical systems and poorly integrated into the existing workflow, potentially limiting their real-world effectiveness. The authors present a review of disease management as well as a conceptual framework to guide the development of more effective health information technology (HIT) tools for translating clinical information into clinical action.

Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care.

PubMed

Kovacs, Eva; Strobl, Ralf; Phillips, Amanda; Stephan, Anna-Janina; Müller, Martin; Gensichen, Jochen; Grill, Eva

2018-05-04

As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs). The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results. The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]). Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.

Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan

PubMed Central

Teich, Jonathan M.; Osheroff, Jerome A.; Pifer, Eric A.; Sittig, Dean F.; Jenders, Robert A.

2005-01-01

Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption. PMID:15802474

Annual Research Review: Building a science of personalized intervention for youth mental health.

PubMed

Ng, Mei Yi; Weisz, John R

2016-03-01

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health. The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics. The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families. © 2015 Association for Child and Adolescent Mental Health.

Evaluation of clinical pharmacy interventions in a Veterans Affairs medical center primary care clinic.

PubMed

Hough, Augustus; Vartan, Christine M; Groppi, Julie A; Reyes, Sonia; Beckey, Nick P

2013-07-01

The development of an electronic tool to quantify and characterize the interventions made by clinical pharmacy specialists (CPSs) in a primary care setting is described. An electronic clinical tool was developed to document the clinical pharmacy interventions made by CPSs at the Veterans Affairs Medical Center in West Palm Beach, Florida. The tool, embedded into the electronic medical record, utilizes a novel reminder dialogue to complete pharmacotherapy visit encounters and allows CPSs to document interventions made during patient care visits. Interventions are documented using specific electronic health factors so that the type and number of interventions made for both disease-specific and other pharmacotherapy interventions can be tracked. These interventions were assessed and analyzed to evaluate the impact of CPSs in the primary care setting. From February 2011 through January 2012, a total of 16,494 pharmacotherapy interventions (therapeutic changes and goals attained) were recorded. The average numbers of interventions documented per patient encounter were 0.96 for the management of diabetes mellitus, hypertension, dyslipidemia, and heart failure and 1.36 for non-disease-specific interventions, independent of those interventions being made by the primary physician or other members of the primary care team. A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

Integrating evidence-based interventions into client care plans.

PubMed

Doran, Diane; Carryer, Jennifer; Paterson, Jane; Goering, Paula; Nagle, Lynn; Kushniruk, Andre; Bajnok, Irmajean; Clark, Carrie; Srivastava, Rani

2009-01-01

Within the mental health care system, there is an opportunity to improve patient safety and the overall quality of care by integrating clinical practice guidelines with the care planning process through the use of information technology. Electronic assessment tools such as the Resident Assessment Inventory - Mental Health (RAI-MH) are widely used to identify the health care needs and outcomes of clients. In this knowledge translation initiative, an electronic care planning tool was enhanced to include evidence-based clinical interventions from schizophrenia guidelines. This paper describes the development of a mental health decision support prototype, a field test by clinicians, and user experiences with the application.

Comparing the Efficacy of a Mobile Phone-Based Blood Glucose Management System With Standard Clinic Care in Women With Gestational Diabetes: Randomized Controlled Trial.

PubMed

Mackillop, Lucy; Hirst, Jane Elizabeth; Bartlett, Katy Jane; Birks, Jacqueline Susan; Clifton, Lei; Farmer, Andrew J; Gibson, Oliver; Kenworthy, Yvonne; Levy, Jonathan Cummings; Loerup, Lise; Rivero-Arias, Oliver; Ming, Wai-Kit; Velardo, Carmelo; Tarassenko, Lionel

2018-03-20

Treatment of hyperglycemia in women with gestational diabetes mellitus (GDM) is associated with improved maternal and neonatal outcomes and requires intensive clinical input. This is currently achieved by hospital clinic attendance every 2 to 4 weeks with limited opportunity for intervention between these visits. We conducted a randomized controlled trial to determine whether the use of a mobile phone-based real-time blood glucose management system to manage women with GDM remotely was as effective in controlling blood glucose as standard care through clinic attendance. Women with an abnormal oral glucose tolerance test before 34 completed weeks of gestation were individually randomized to a mobile phone-based blood glucose management solution (GDm-health, the intervention) or routine clinic care. The primary outcome was change in mean blood glucose in each group from recruitment to delivery, calculated with adjustments made for number of blood glucose measurements, proportion of preprandial and postprandial readings, baseline characteristics, and length of time in the study. A total of 203 women were randomized. Blood glucose data were available for 98 intervention and 85 control women. There was no significant difference in rate of change of blood glucose (-0.16 mmol/L in the intervention and -0.14 mmol/L in the control group per 28 days, P=.78). Women using the intervention had higher satisfaction with care (P=.049). Preterm birth was less common in the intervention group (5/101, 5.0% vs 13/102, 12.7%; OR 0.36, 95% CI 0.12-1.01). There were fewer cesarean deliveries compared with vaginal deliveries in the intervention group (27/101, 26.7% vs 47/102, 46.1%, P=.005). Other glycemic, maternal, and neonatal outcomes were similar in both groups. The median time from recruitment to delivery was similar (intervention: 54 days; control: 49 days; P=.23). However, there were significantly more blood glucose readings in the intervention group (mean 3.80 [SD 1.80] and mean 2.63 [SD 1.71] readings per day in the intervention and control groups, respectively; P<.001). There was no significant difference in direct health care costs between the two groups, with a mean cost difference of the intervention group compared to control of -£1044 (95% CI -£2186 to £99). There were no unexpected adverse outcomes. Remote blood glucocse monitoring in women with GDM is safe. We demonstrated superior data capture using GDm-health. Although glycemic control and maternal and neonatal outcomes were similar, women preferred this model of care. Further studies are required to explore whether digital health solutions can promote desired self-management lifestyle behaviors and dietetic adherence, and influence maternal and neonatal outcomes. Digital blood glucose monitoring may provide a scalable, practical method to address the growing burden of GDM around the world. ClinicalTrials.gov NCT01916694; https://clinicaltrials.gov/ct2/show/NCT01916694 (Archived by WebCite at http://www.webcitation.org/6y3lh2BOQ). ©Lucy Mackillop, Jane Elizabeth Hirst, Katy Jane Bartlett, Jacqueline Susan Birks, Lei Clifton, Andrew J Farmer, Oliver Gibson, Yvonne Kenworthy, Jonathan Cummings Levy, Lise Loerup, Oliver Rivero-Arias, Wai-Kit Ming, Carmelo Velardo, Lionel Tarassenko. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 20.03.2018.

Elder Abuse and Neglect Intervention in the Clinical Setting: Perceptions and Barriers Faced by Primary Care Physicians in Malaysia.

PubMed

Mohd Mydin, Fadzilah Hanum; Othman, Sajaratulnisah

2017-08-01

This qualitative study attempts to explore the definition, perceptions, practice experience, and barriers of primary care physicians (PCPs) in identifying and intervening in cases of elder abuse and neglect at the primary care level. Semistructured in-depth interview was conducted among 10 PCPs. Participants were selected by purposive sampling. The interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. In general, PCPs showed consistency in defining elder abuse and neglect. PCPs considered that they were optimally positioned to intervene in cases of elder abuse and neglect, but indicated the potential of overlooking such problems. The hurdles faced by PCPs in the identification and intervention of elder abuse were determined to be occurring at three levels: clinical, organizational, and policy. At the clinical level, PCPs recognize that they are lacking both the confidence and knowledge of elder abuse and neglect intervention. PCPs' conflicting personal and professional beliefs create barriers during the clinical practice. Time constraints, patients' other clinical problems, and, in addition, the preservation of a good doctor-patient relationship overshadow the importance of addressing and intervening in elder abuse and neglect issues during the consultation. This is further exacerbated by the barriers perceived by the patients: their nondisclosure and reluctance to accept outside intervention. At the organizational level, the lack of efficient interagency networks or support for the health system poses barriers. At the policy level, the absence of legislation specifically addressing elder abuse also creates considerable difficulties. However, PCPs gave differing responses when asked about a law concerning the elderly and mandatory reporting. Addressing these multilevel barriers is critical for ensuring that opportunities arising at the primary care level for elder maltreatment intervention are correctly utilized.

Effectiveness and acceptance of a web-based depression intervention during waiting time for outpatient psychotherapy: study protocol for a randomized controlled trial.

PubMed

Grünzig, Sasha-Denise; Baumeister, Harald; Bengel, Jürgen; Ebert, David; Krämer, Lena

2018-05-22

Due to limited resources, waiting periods for psychotherapy are often long and burdening for those in need of treatment and the health care system. In order to bridge the gap between initial contact and the beginning of psychotherapy, web-based interventions can be applied. The implementation of a web-based depression intervention during waiting periods has the potential to reduce depressive symptoms and enhance well-being in depressive individuals waiting for psychotherapy. In a two-arm randomized controlled trial, effectiveness and acceptance of a guided web-based intervention for depressive individuals on a waitlist for psychotherapy are evaluated. Participants are recruited in several German outpatient clinics. All those contacting the outpatient clinics with the wish to enter psychotherapy receive study information and a depression screening. Those adults (age ≥ 18) with depressive symptoms above cut-off (CES-D scale > 22) and internet access are randomized to either intervention condition (treatment as usual and immediate access to the web-based intervention) or waiting control condition (treatment as usual and delayed access to the web-based intervention). At three points of assessment (baseline, post-treatment, 3-months-follow-up) depressive symptoms and secondary outcomes, such as quality of life, attitudes towards psychotherapy and web-based interventions and adverse events are assessed. Additionally, participants' acceptance of the web-based intervention is evaluated, using measures of intervention adherence and satisfaction. This study investigates a relevant setting for the implementation of web-based interventions, potentially improving the provision of psychological health care. The results of this study contribute to the evaluation of innovative and resource-preserving health care models for outpatient psychological treatment. This trial has been registered on 13 February 2017 in the German clinical trials register (DRKS); registration number DRKS00010282 .

Connect for Health: Design of a Clinical-Community Childhood Obesity Intervention Testing Best Practices of Positive Outliers

PubMed Central

Taveras, Elsie M.; Marshall, Richard; Sharifi, Mona; Avalon, Earlene; Fiechtner, Lauren; Horan, Christine; Orav, John; Price, Sarah N.; Sequist, Thomas; Slater, Daniel

2016-01-01

Background The Connect for Health study is designed to assess whether a novel approach to care delivery that leverages clinical and community resources and addresses socio-contextual factors will improve body mass index (BMI) and family-centered, obesity-related outcomes of interest to parents and children. The intervention is informed by clinical, community, parent, and youth stakeholders and incorporates successful strategies and best practices learned from ‘positive outlier” families, i.e., those who have succeeded in changing their health behaviors and improve their BMI in the context of adverse built and social environments. Design Two-arm, randomized controlled trial with measures at baseline and 12 months after randomization. Participants 2-12 year old children with overweight or obesity (BMI≥ 85th percentile) and their parents/guardians recruited from 6 pediatric practices in eastern Massachusetts. Intervention Children randomized to the intervention arm receive a contextually-tailored intervention delivered by trained health coaches who use advanced geographic information system tools to characterize children's environments and neighborhood resources. Health coaches link families to community-level resources and use multiple support modalities including text messages and virtual visits to support families over a one-year intervention period. The control group receives enhanced pediatric care plus non-tailored health coaching. Main Outcome Measures Lower age-associated increase in BMI over a 1-year period. The main parent- and child-reported outcome is improved health-related quality of life. Conclusions The Connect for Health study seeks to support families in leveraging clinical and community resources to improve obesity-related outcomes that are most important to parents and children. PMID:26427562

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes

PubMed Central

Oles, Sylwia K.; Mundell, James; London, Susan; Khan, Babar

2016-01-01

Objective The purpose of this scoping review was to identify evidence describing benefits of interventions provided in ICU-survivor follow-up clinics. Background Advances in intensive care unit (ICU) treatments have increased the number of survivors who require specialized care for ICU-related sequelae. ICU survivor follow-up clinics exist yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken. Method Ten databases were searched yielding one-hundred eleven relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding non-related publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes. Results Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms whereas evidence to support implementation of other interventions was weak. Conclusions Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains under-explored. Implications ICU survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors. PMID:27309787

A clinical nurse specialist-led intervention to enhance medication adherence using the plan-do-check-act cycle for continuous self-improvement.

PubMed

Russell, Cynthia L

2010-01-01

A clinical nurse specialist-led intervention to improve medication adherence in chronically ill adults using renal transplant recipients as an exemplar population is proposed. Meta-analyses and systematic reviews of chronically ill and transplant patients indicate that patient-specific characteristics not only are poor and inconsistent predictors for medication nonadherence but also are not amenable to intervention. Adherence has not meaningfully improved, despite meta-analyses and systematic narrative reviews of randomized controlled trials (RCTs) dealing with medication nonadherence in acutely and chronically ill persons and RCTs dealing with transplant patients. Interventions with a superior potential to enhance medication adherence must be developed. Use of a clinical nurse specialist-led continuous self-improvement intervention with adult renal transplant recipients is proposed. Continuous self-improvement focuses on improving personal systems thinking and behavior using the plan-do-check-act process. Electronic medication monitoring reports, one of several objective measures of medication adherence, are used by the clinician to provide patient feedback during the check process on medication-taking patterns. Continuous self-improvement as an intervention holds promise in supporting patient self-management and diminishing the blame that clinicians place on patients for medication nonadherence. Using an objective measure of medication adherence such as an electronic monitoring report fosters collaborative patient-clinician discussions of daily medication-taking patterns. Through collaboration, ideas for improving medication taking can be explored. Changes can be followed and evaluated for effectiveness through the continuous self-improvement process. Future studies should include RCTs comparing educational and/or behavioral interventions to improve medication adherence.

An ethnography of clinic "noise" in a community-based, promotora-centered mental health intervention.

PubMed

Getrich, Christina; Heying, Shirley; Willging, Cathleen; Waitzkin, Howard

2007-07-01

Community-based health interventions have emerged as a growing focus for anthropological research. The application of ethnographic approaches in clinical practice settings reveals that community-based interventions must grapple with "noise," or unanticipated factors such as patients' own perceptions of illness and treatment, primary care providers' non-adherence to guidelines-based treatment, the social dynamics of the clinic site itself, and incomplete understanding and acceptance of an intervention by a clinic's staff members. Such noise can influence the implementation and quality of treatment. Thus, identifying clinic-based noise is critical in assessments of fidelity to intervention protocols as well as outcomes of community-based interventions. This paper highlights findings from an evaluation of a mental health intervention focusing on the role of promotoras (briefly trained, non-professional community health workers) as mental health practitioners in two urban New Mexico, USA, community health centers. Our research identified three areas of clinic-based noise: the clinics' physical ability to "absorb" the intervention, the challenges of co-worker instability and interpersonal relationships, and balancing extra workplace demands. The findings demonstrate the value of ethnographic approaches in community-based intervention research.

How current Clinical Practice Guidelines for low back pain reflect Traditional Medicine in East Asian Countries: a systematic review of Clinical Practice Guidelines and systematic reviews.

PubMed

Cho, Hyun-Woo; Hwang, Eui-Hyoung; Lim, Byungmook; Heo, Kwang-Ho; Liu, Jian-Ping; Tsutani, Kiichiro; Lee, Myeong Soo; Shin, Byung-Cheul

2014-01-01

The aims of this study were to investigate whether there is a gap between evidence of traditional medicine (TM) interventions in East-Asian countries from the current Clinical Practice Guidelines (CPGs) and evidence from current systematic reviews and meta-analyses (SR-MAs) and to analyze the impact of this gap on present CPGs. We examined 5 representative TM interventions in the health care systems of East-Asian countries. We searched seven relevant databases for CPGs to identify whether core CPGs included evidence of TM interventions, and we searched 11 databases for SR-MAs to re-evaluate current evidence on TM interventions. We then compared the gap between the evidence from CPGs and SR-MAs. Thirteen CPGs and 22 SR-MAs met our inclusion criteria. Of the 13 CPGs, 7 CPGs (54%) mentioned TM interventions, and all were for acupuncture (only one was for both acupuncture and acupressure). However, the CPGs did not recommend acupuncture (or acupressure). Of 22 SR-MAs, 16 were for acupuncture, 5 for manual therapy, 1 for cupping, and none for moxibustion and herbal medicine. Comparing the evidence from CPGs and SR-MAs, an underestimation or omission of evidence for acupuncture, cupping, and manual therapy in current CPGs was detected. Thus, applying the results from the SR-MAs, we moderately recommend acupuncture for chronic LBP, but we inconclusively recommend acupuncture for (sub)acute LBP due to the limited current evidence. Furthermore, we weakly recommend cupping and manual therapy for both (sub)acute and chronic LBP. We cannot provide recommendations for moxibustion and herbal medicine due to a lack of evidence. The current CPGs did not fully reflect the evidence for TM interventions. As relevant studies such as SR-MAs are conducted and evidence increases, the current evidence on acupuncture, cupping, and manual therapy should be rigorously considered in the process of developing or updating the CPG system.

Health care barriers and interventions for battered women.

PubMed Central

Loring, M T; Smith, R W

1994-01-01

Family violence is a major public health problem. Battered women present with multiple physical injuries in hospital emergency rooms, clinics, and personal physicians' offices. Yet, they are often not identified as battered and fail to receive appropriate treatment for the nonphysical effects of these events. Instead, only discrete physical injuries are identified. The authors explore the literature to identify barriers in recognizing and treating battered women. These barriers are viewed as a microcosm of the larger public health problem in which battered women fear identifying themselves and often are not recognized by public health professionals. Some barriers pertain to the victims themselves; others can be attributed to the attitudes of medical care providers in emergency rooms, clinics, and private physicians' offices. The many faceted needs of victims require a variety of interventions including medical models, criminal justice intervention systems, and social models for change. Some intervention strategies that are currently being employed in various programs in the United States are described. PMID:8190856

Incorporating INTERACT II Clinical Decision Support Tools into Nursing Home Health Information Technology

PubMed Central

Handler, Steven M.; Sharkey, Siobhan S.; Hudak, Sandra; Ouslander, Joseph G.

2012-01-01

A substantial reduction in hospitalization rates has been associated with the implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement intervention using the accompanying paper-based clinical practice tools (INTERACT II). There is significant potential to further increase the impact of INTERACT by integrating INTERACT II tools into nursing home (NH) health information technology (HIT) via standalone or integrated clinical decision support (CDS) systems. This article highlights the process of translating INTERACT II tools from paper to NH HIT. The authors believe that widespread dissemination and integration of INTERACT II CDS tools into various NH HIT products could lead to sustainable improvement in resident and clinician process and outcome measures, including enhanced interclinician communication and a reduction in potentially avoidable hospitalizations. PMID:22267955

Review of electronic decision-support tools for diabetes care: a viable option for low- and middle-income countries?

PubMed

Ali, Mohammed K; Shah, Seema; Tandon, Nikhil

2011-05-01

Diabetes care is complex, requiring motivated patients, providers, and systems that enable guideline-based preventative care processes, intensive risk-factor control, and positive lifestyle choices. However, care delivery in low- and middle-income countries (LMIC) is hindered by a compendium of systemic and personal factors. While electronic medical records (EMR) and computerized clinical decision-support systems (CDSS) have held great promise as interventions that will overcome system-level challenges to improving evidence-based health care delivery, evaluation of these quality improvement interventions for diabetes care in LMICs is lacking. OBJECTIVE AND DATA SOURCES: We reviewed the published medical literature (systematic search of MEDLINE database supplemented by manual searches) to assess the quantifiable and qualitative impacts of combined EMR-CDSS tools on physician performance and patient outcomes and their applicability in LMICs. Inclusion criteria prespecified the population (type 1 or 2 diabetes patients), intervention (clinical EMR-CDSS tools with enhanced functionalities), and outcomes (any process, self-care, or patient-level data) of interest. Case, review, or methods reports and studies focused on nondiabetes, nonclinical, or in-patient uses of EMR-CDSS were excluded. Quantitative and qualitative data were extracted from studies by separate single reviewers, respectively, and relevant data were synthesized. Thirty-three studies met inclusion criteria, originating exclusively from high-income country settings. Among predominantly experimental study designs, process improvements were consistently observed along with small, variable improvements in risk-factor control, compared with baseline and/or control groups (where applicable). Intervention benefits varied by baseline patient characteristics, features of the EMR-CDSS interventions, motivation and access to technology among patients and providers, and whether EMR-CDSS tools were combined with other quality improvement strategies (e.g., workflow changes, case managers, algorithms, incentives). Patients shared experiences of feeling empowered and benefiting from increased provider attention and feedback but also frustration with technical difficulties of EMR-CDSS tools. Providers reported more efficient and standardized processes plus continuity of care but also role tensions and "mechanization" of care. This narrative review supports EMR-CDSS tools as innovative conduits for structuring and standardizing care processes but also highlights setting and selection limitations of the evidence reviewed. In the context of limited resources, individual economic hardships, and lack of structured systems or trained human capital, this review reinforces the need for well-designed investigations evaluating the role and feasibility of technological interventions (customized to each LMIC's locality) in clinical decision making for diabetes care. © 2011 Diabetes Technology Society.

Rubber stamp templates for improving clinical documentation: A paper-based, m-Health approach for quality improvement in low-resource settings.

PubMed

Kleczka, Bernadette; Musiega, Anita; Rabut, Grace; Wekesa, Phoebe; Mwaniki, Paul; Marx, Michael; Kumar, Pratap

2018-06-01

The United Nations' Sustainable Development Goal #3.8 targets 'access to quality essential healthcare services'. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones. The Guidelines Adherence in Slums Project targeted ten private sector primary healthcare clinics serving informal settlements in Nairobi, Kenya. Each clinic was provided with rubber stamp templates to support documentation and management of commonly encountered outpatient conditions. Participatory design methods were used to customize templates to the workflows and infrastructure of each clinic. Rubber stamps were used to print templates into paper charts, providing clinicians with checklists for use during consultations. Templates used bubble format data entry, which could be digitized from images taken on mobile phones. Besides rubber stamp templates, the intervention included booklets of guideline compilations, one Android phone for digitizing images of templates, and one data feedback/continuing medical education session per clinic each month. In this paper we focus on the effect of the intervention on documentation of three non-communicable diseases in one clinic. Seventy charts of patients enrolled in the chronic disease program (hypertension/diabetes, n=867; chronic respiratory diseases, n=223) at one of the ten intervention clinics were sampled. Documentation of each individual patient encounter in the pre-intervention (January-March 2016) and post-intervention period (May-July) was scored for information in four dimensions - general data, patient assessment, testing, and management. Control criteria included information with no counterparts in templates (e.g. notes on presenting complaints, vital signs). Documentation scores for each patient were compared between both pre- and post-intervention periods and between encounters documented with and without templates (post-intervention only). The total number of patient encounters in the pre-intervention (282) and post-intervention periods (264) did not differ. Mean documentation scores increased significantly in the post-intervention period on average by 21%, 24% and 17% for hypertension, diabetes and chronic respiratory diseases, respectively. Differences were greater (47%, 43% and 27%, respectively) when documentation with and without templates was compared. Changes between pre- vs.post-intervention, and with vs.without template, varied between individual dimensions of documentation. Overall, documentation improved more for general data and patient assessment than in testing or management. The use of templates improves paper-based documentation of patient care, a first step towards improving the quality of care. Rubber stamps provide a simple and low-cost method to print templates on demand. In combination with ubiquitously available mobile phones, information entered on paper can be easily and rapidly digitized. This 'frugal innovation' in m-Health can empower small, private sector facilities, where large numbers of urban patients seek healthcare, to generate digital data on routine outpatient care. These data can form the basis for evidence-based quality improvement efforts at large scale, and help deliver on the SDG promise of quality essential healthcare services for all. Copyright © 2017 Elsevier B.V. All rights reserved.

Impact of pharmacy student interventions in an urban family medicine clinic.

PubMed

Ginzburg, Regina

2014-06-17

To determine the number of interventions made by pharmacy students at an urban family medicine clinic and the acceptance rate of these recommendations by the healthcare providers. The secondary objective was to investigate the cost avoidance value of the interventions. A prospective, unblinded study was conducted to determine the number and cost avoidance value of clinical interventions made by pharmacy students completing advanced pharmacy practice experiences (APPEs) in an urban family medicine clinic. Eighteen students completed this experience in the 8 months studied. Of the 718 interventions performed, 77% were accepted by physicians, including 58% of the 200 interventions that required immediate action. Projected avoidance was estimated at $61,855. The clinical interventions by pharmacy students were generally well received by healthcare providers and resulted in significant cost savings. Pharmacy students can play an important role in a family medicine clinic.

Intervention Techniques Used With Autism Spectrum Disorder by Speech-Language Pathologists in the United States and Taiwan: A Descriptive Analysis of Practice in Clinical Settings.

PubMed

Hsieh, Ming-Yeh; Lynch, Georgina; Madison, Charles

2018-04-27

This study examined intervention techniques used with children with autism spectrum disorder (ASD) by speech-language pathologists (SLPs) in the United States and Taiwan working in clinic/hospital settings. The research questions addressed intervention techniques used with children with ASD, intervention techniques used with different age groups (under and above 8 years old), and training received before using the intervention techniques. The survey was distributed through the American Speech-Language-Hearing Association to selected SLPs across the United States. In Taiwan, the survey (Chinese version) was distributed through the Taiwan Speech-Language Pathologist Union, 2018, to certified SLPs. Results revealed that SLPs in the United States and Taiwan used 4 common intervention techniques: Social Skill Training, Augmentative and Alternative Communication, Picture Exchange Communication System, and Social Stories. Taiwanese SLPs reported SLP preparation program training across these common intervention strategies. In the United States, SLPs reported training via SLP preparation programs, peer therapists, and self-taught. Most SLPs reported using established or emerging evidence-based practices as defined by the National Professional Development Center (2014) and the National Standards Report (2015). Future research should address comparison of SLP preparation programs to examine the impact of preprofessional training on use of evidence-based practices to treat ASD.

A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series.

PubMed

Marwick, Charis A; Guthrie, Bruce; Pringle, Jan E C; Evans, Josie M M; Nathwani, Dilip; Donnan, Peter T; Davey, Peter G

2014-12-01

Antibiotic administration to inpatients developing sepsis in general hospital wards was frequently delayed. We aimed to reproduce improvements in sepsis management reported in other settings. Ninewells Hospital, an 860-bed teaching hospital with quality improvement (QI) experience, in Scotland, UK. The intervention wards were 22 medical, surgical and orthopaedic inpatient wards. A multifaceted intervention, informed by baseline process data and questionnaires and interviews with junior doctors, evaluated using segmented regression analysis of interrupted time series (ITS) data. MEASURES FOR IMPROVEMENT: Primary outcome measure: antibiotic administration within 4 hours of sepsis onset. Secondary measures: antibiotics within 8 hours; mean and median time to antibiotics; medical review within 30 min for patients with a standardised early warning system score .4; blood cultures taken before antibiotic administration; blood lactate level measured. The intervention included printed and electronic clinical guidance, educational clinical team meetings including baseline performance data, audit and monthly feedback on performance. Performance against all study outcome measures improved postintervention but differences were small and ITS analysis did not attribute the observed changes to the intervention. Rigorous analysis of this carefully designed improvement intervention could not confirm significant effects. Statistical analysis of many such studies is inadequate, and there is insufficient reporting of negative studies. In light of recent evidence, involving senior clinical team members in verbal feedback and action planning may have made the intervention more effective. Our focus on rigorous intervention design and evaluation was at the expense of iterative refinement, which likely reduced the effect. This highlights the necessary, but challenging, requirement to invest in all three components for effective QI.

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

PubMed Central

Cummings, Amanda; Lund, Susi; Campling, Natasha; May, Carl; Richardson, Alison; Myall, Michelle

2017-01-01

Objectives To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration. Design and methods A scoping review was undertaken based on the methodological framework of Arksey and O’Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes. Results Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal. Conclusions A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions. PMID:28988176

[Interventional radiology treatment of extensive pulmonary embolism and thromboembolic diseases].

PubMed

Battyáni, István; Dósa, Edit; Harmat, Zoltán

2015-04-26

The authors discuss interventional radiological methods in the field of vascular interventions applied in venous system diseases. Venous diseases can be life threatening without appropriate treatment and can lead to chronic venous diseases and venous insufficiency with long-term reduction in the quality of life. In addition, recurrent clinical symptoms require additional treatments. Interventional radiology has several methods that can provide fast and complete recovery if applied in time. The authors summarize these methods hoping that they will be available for a wide range of patients through the establishment of Interventional Radiological Centres and will be a part of the daily routine of patient care. Regarding the frequency of venous diseases and its influance on life quality the authors would like to draw attention to interventional radiological techniques and modern therapeutic possibilities.

Multi-level assessment protocol (MAP) for adoption in multi-site clinical trials

PubMed Central

Guydish, J.; Manser, S.T.; Jessup, M.; Tajima, B.; Sears, C.; Montini, T.

2010-01-01

The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) is intended to test promising drug abuse treatment models in multi-site clinical trials, and to support adoption of new interventions into clinical practice. Using qualitative research methods we asked: How might the technology of multi-site clinical trials be modified to better support adoption of tested interventions? A total of 42 participants, representing 8 organizational levels ranging from clinic staff to clinical trial leaders, were interviewed about their role in the clinical trial, its interactions with clinics, and intervention adoption. Among eight clinics participating in the clinical trial, we found adoption of the tested intervention in one clinic only. In analysis of interview data we identified four conceptual themes which are likely to affect adoption and may be informative in future multi-site clinical trials. We offer the conclusion that planning for adoption in the early stages of protocol development will better serve the aim of integrating new interventions into practice. PMID:20890376

Mentoring, coaching and action learning: interventions in a national clinical leadership development programme.

PubMed

McNamara, Martin S; Fealy, Gerard M; Casey, Mary; O'Connor, Tom; Patton, Declan; Doyle, Louise; Quinlan, Christina

2014-09-01

To evaluate mentoring, coaching and action learning interventions used to develop nurses' and midwives' clinical leadership competencies and to describe the programme participants' experiences of the interventions. Mentoring, coaching and action learning are effective interventions in clinical leadership development and were used in a new national clinical leadership development programme, introduced in Ireland in 2011. An evaluation of the programme focused on how participants experienced the interventions. A qualitative design, using multiple data sources and multiple data collection methods. Methods used to generate data on participant experiences of individual interventions included focus groups, individual interviews and nonparticipant observation. Seventy participants, including 50 programme participants and those providing the interventions, contributed to the data collection. Mentoring, coaching and action learning were positively experienced by participants and contributed to the development of clinical leadership competencies, as attested to by the programme participants and intervention facilitators. The use of interventions that are action-oriented and focused on service development, such as mentoring, coaching and action learning, should be supported in clinical leadership development programmes. Being quite different to short attendance courses, these interventions require longer-term commitment on the part of both individuals and their organisations. In using mentoring, coaching and action learning interventions, the focus should be on each participant's current role and everyday practice and on helping the participant to develop and demonstrate clinical leadership skills in these contexts. © 2014 John Wiley & Sons Ltd.

Enhancing Periconceptional Health by Targeting Postpartum Mothers at Rural WIC Clinics.

PubMed

Puma, Jini E; Thompson, Darcy; Baer, Katherine; Haemer, Matthew A; Gilbert, Kevin; Hambidge, Michael; Krebs, Nancy F

2018-05-01

The overall goal of this pilot quality improvement (QI) intervention was to (1) assess the feasibility of making a WIC (Women, Infants, and Children) systems-level change that added measurement of maternal weight and discussion of maternal health habits into each postpartum maternal and offspring visit in rural clinics in Colorado and (2) assess the impacts of the intervention on maternal diet, physical activity, and weight status. A mixed-method evaluation approach was used involving the collection of quantitative data (HeartSmartMoms usage reports, manual WIC chart reviews [to calculate screening rates], pre-/postsurveys, and weight status [body mass index]) and qualitative data (focus groups and project team meeting minutes). It was determined it is feasible to make a short-term systems-level change; however, many barriers were encountered in doing so, and the results were not sustained. The QI intervention did decrease participants' daily consumption of sugar-sweetened beverages and maternal weight status (controlling for maternal age and language), but did not improve any other eating/physical activity behaviors. Lessons learned and recommendations to improve the implementation of health promotion interventions aimed at improving postpartum maternal health, which can increase health during the periconceptional phase, and in turn, improve the health outcomes for a child, are discussed.

Social Support for Diabetes Self-Management via eHealth Interventions.

PubMed

Vorderstrasse, Allison; Lewinski, Allison; Melkus, Gail D'Eramo; Johnson, Constance

2016-07-01

eHealth interventions have been increasingly used to provide social support for self-management of type 2 diabetes. In this review, we discuss social support interventions, types of support provided, sources or providers of support, outcomes of the support interventions (clinical, behavioral, psychosocial), and logistical and clinical considerations for support interventions using eHealth technologies. Many types of eHealth interventions demonstrated improvements in self-management behaviors, psychosocial outcomes, and clinical measures, particularly HbA1c. Important factors to consider in clinical application of eHealth support interventions include participant preferences, usability of eHealth technology, and availability of personnel to orient or assist participants. Overall, eHealth is a promising adjunct to clinical care as it addresses the need for ongoing support in chronic disease management.

Clinic-wide Intervention Lowers Financial Risk and Improves Revenue to HIV Clinics Through Fewer Missed Primary Care Visits

PubMed Central

Gardner, Lytt I.; Marks, Gary; Wilson, Tracey E.; Giordano, Thomas P.; Sullivan, Meg; Raper, James L.; Rodriguez, Allan E.; Keruly, Jeanne; Malitz, Faye

2016-01-01

We calculated the financial impact in 6 HIV clinics of a low-effort retention in care intervention involving brief motivational messages from providers, patient brochures, and posters. We used a linear regression model to calculate absolute changes in kept primary care visits from the preintervention year (2008–2009) to the intervention year (2009–2010). Revenue from patients’ insurance was also assessed by clinic. Kept visits improved significantly in the intervention year versus the preintervention year (P < 0.0001). We found a net-positive effect on clinic revenue of +$24,000/year for an average-size clinic (7400 scheduled visits/year). We encourage HIV clinic administrators to consider implementing this low-effort intervention. PMID:25559605

Physicians and pharmacists: collaboration to improve the quality of prescriptions in primary care in Mexico.

PubMed

Mino-León, Dolores; Reyes-Morales, Hortensia; Jasso, Luis; Douvoba, Svetlana Vladislavovna

2012-06-01

Inappropriate prescription is a relevant problem in primary health care settings in Mexico, with potentially harmful consequences for patients. To evaluate the effectiveness of incorporating a pharmacist into primary care health team to reduce prescription errors for patients with diabetes and/or hypertension. One Family Medicine Clinic from the Mexican Institute of Social Security in Mexico City. A "pharmacotherapy intervention" provided by pharmacists through a quasi experimental (before-after) design was carried out. Physicians who allowed access to their diabetes and/or hypertensive patients' medical records and prescriptions were included in the study. Prescription errors were classified as "filling", "clinical" or "both". Descriptive analysis, identification of potential drug-drug interactions (pD-DI), and comparison of the proportion of patients with prescriptions with errors detected "before" and "after" intervention were performed. Decrease in the proportion of patients who received prescriptions with errors after the intervention. Pharmacists detected at least one type of error in 79 out of 160 patients. Errors were "clinical", "both" and "filling" in 47, 21 and 11 of these patient's prescriptions respectively. Predominant errors were, in the subgroup of patient's prescriptions with "clinical" errors, pD-DI; in the subgroup of "both" errors, lack of information on dosing interval and pD-DI; and in the "filling" subgroup, lack of information on dosing interval. The pD-DI caused 50 % of the errors detected, from which 19 % were of major severity. The impact of the correction of errors post-intervention was observed in 19 % of patients who had erroneous prescriptions before the intervention of the pharmacist (49.3-30.3 %, p < 0.05). The impact of the intervention was relevant from a clinical point of view for the public health services in Mexico. The implementation of early warning systems of the most widely prescribed drugs is an alternative for reducing prescription errors and consequently the risks they may cause.

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives

PubMed Central

Henke, Rachel Mosher; Chou, Ann F; Chanin, Johann C; Zides, Amanda B; Scholle, Sarah Hudson

2008-01-01

Background Few individuals with depression treated in the primary care setting receive care consistent with clinical treatment guidelines. Interventions based on the chronic care model (CCM) have been promoted to address barriers and improve the quality of care. A current understanding of barriers to depression care and an awareness of whether physicians believe interventions effectively address those barriers is needed to enhance the success of future implementation. Methods We conducted semi-structured interviews with 23 primary care physicians across the US regarding their experience treating patients with depression, barriers to care, and commonly promoted CCM-based interventions. Themes were identified from interview transcripts using a grounded theory approach. Results Six barriers emerged from the interviews: difficulty diagnosing depression, patient resistance, fragmented mental health system, insurance coverage, lack of expertise, and competing demands and other responsibilities as a primary care provider. A number of interventions were seen as helpful in addressing these barriers – including care managers, mental health integration, and education – while others received mixed reviews. Mental health consultation models received the least endorsement. Two systems-related barriers, the fragmented mental health system and insurance coverage limitations, appeared incompletely addressed by the interventions. Conclusion CCM-based interventions, which include care managers, mental health integration, and patient education, are most likely to be implemented successfully because they effectively address several important barriers to care and are endorsed by physicians. Practices considering the adoption of interventions that received less support should educate physicians about the benefit of the interventions and attend to physician concerns prior to implementation. A focus on interventions that address systems-related barriers is needed to overcome all barriers to care. PMID:18826646

Designing for Clinical Change: Creating an Intervention to Implement New Statin Guidelines in a Primary Care Clinic.

PubMed

DeJonckheere, Melissa; Robinson, Claire H; Evans, Lindsey; Lowery, Julie; Youles, Bradley; Tremblay, Adam; Kelley, Caitlin; Sussman, Jeremy B

2018-04-24

Recent clinical practice guidelines from major national organizations, including a joint United States Department of Veterans Affairs (VA) and Department of Defense (DoD) committee, have substantially changed recommendations for the use of the cholesterol-lowering statin medications after years of relative stability. Because statin medications are among the most commonly prescribed treatments in the United States, any change in their use may have significant implications for patients and providers alike. Prior research has shown that effective implementation interventions should be both user centered and specifically chosen to address identified barriers. The objectives of this study were to identify potential determinants of provider uptake of the new statin guidelines and to use that information to tailor a coordinated and streamlined local quality improvement intervention focused on prescribing appropriate statins. We employed user-centered design principles to guide the development and testing of a multicomponent guideline implementation intervention to improve statin prescribing. This paper describes the intervention development process whereby semistructured qualitative interviews with providers were conducted to (1) illuminate the knowledge, attitudes, and behaviors of providers and (2) elicit feedback on intervention prototypes developed to align with and support the use of the VA/DoD guidelines. Our aim was to use this information to design a local quality improvement intervention focused on statin prescribing that was tailored to the needs of primary care providers at our facility. Cabana's Clinical Practice Guidelines Framework for Improvement and Nielsen's Usability Heuristics were used to guide the analysis of data obtained in the intervention development process. Semistructured qualitative interviews were conducted with 15 primary care Patient Aligned Care Team professionals (13 physicians and 2 clinical pharmacists) at a single VA medical center. Findings highlight that providers were generally comfortable with the paradigm shift to risk-based guidelines but less clear on the need for the VA/DoD guidelines in specific. Providers preferred a clinical decision support tool that helped them calculate patient risk and guide their care without limiting autonomy. They were less comfortable with risk communication and performance measurement systems that do not account for shared decision making. When possible, we incorporated their recommendations into the intervention. By combining qualitative methods and user-centered design principles, we could inform the design of a multicomponent guideline implementation intervention to better address the needs and preferences of providers, including clear and direct language, logical decision prompts with an option to dismiss a clinical decision support tool, and logical ordering of feedback information. Additionally, this process allowed us to identify future design considerations for quality improvement interventions. ©Melissa DeJonckheere, Claire H Robinson, Lindsey Evans, Julie Lowery, Bradley Youles, Adam Tremblay, Caitlin Kelley, Jeremy B Sussman. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 24.04.2018.

Impact of the Provider and Healthcare team Adherence to Treatment Guidelines (PHAT-G) intervention on adherence to national obesity clinical practice guidelines in a primary care centre.

PubMed

Barnes, Emily R; Theeke, Laurie A; Mallow, Jennifer

2015-04-01

Obesity is significantly underdiagnosed and undertreated in primary care settings. The purpose of this clinical practice change project was to increase provider adherence to national clinical practice guidelines for the diagnosis and treatment of obesity in adults. Based upon the National Institutes of Health guidelines for the diagnosis and treatment of obesity, a clinical change project was implemented. Guided by the theory of planned behaviour, the Provider and Healthcare team Adherence to Treatment Guidelines (PHAT-G) intervention includes education sessions, additional provider resources for patient education, a provider reminder system and provider feedback. Primary care providers did not significantly increase on documentation of diagnosis and planned management of obesity for patients with body mass index (BMI) greater than or equal to 30. Medical assistants increased recording of height, weight and BMI in the patient record by 13%, which was significant. Documentation of accurate BMI should lead to diagnosis of appropriate weight category and subsequent care planning. Future studies will examine barriers to adherence to clinical practice guidelines for obesity. Interventions are needed that include inter-professional team members and may be more successful if delivered separately from routine primary care visits. © 2015 John Wiley & Sons, Ltd.

Clinical and economic impact of infusion reactions in patients with colorectal cancer treated with cetuximab

PubMed Central

Foley, K. A.; Wang, P. F.; Barber, B. L.; Long, S. R.; Bagalman, J. E.; Wagner, V.; Song, X.; Zhao, Z.

2010-01-01

Background: Systemic agents in cancer treatment were often associated with possible infusion reactions (IRs). This study estimated the incidence of IRs requiring medical intervention and assessed the clinical and economic impacts of IRs in patients with colorectal cancer (CRC) treated with cetuximab. Patients and methods: Details on patients with CRC receiving cetuximab in 2004–2006 were extracted from a large USA administrative claims database. IRs were identified based on the occurrence of outpatient treatment, emergency room (ER) visit, and/or hospitalization for hypersensitivity and allergic reactions. Multivariate regressions were used to examine potential risk factors and quantify the economic impact of IRs. Results: A total of 1122 CRC patients receiving cetuximab were identified. The incidence of IRs requiring medical intervention was 8.4%. Sixty-eight percent of the patients had treatment disruptions and 34% discontinued cetuximab treatment. Mean adjusted costs were $13 863 for cetuximab administrations with an IR requiring ER visit or hospitalization and $6280 for those with an IR requiring outpatient treatment, compared with $4555 for those without an IR. Conclusions: The incidence rate of cetuximab-related IRs requiring medical intervention in clinical practice was found to be higher than rates reported in the product label and clinical trials. The clinical and economic impacts of these IRs are substantial. PMID:20100773

Feasibility of an Autism-Focused Augmented Reality Smartglasses System for Social Communication and Behavioral Coaching.

PubMed

Liu, Runpeng; Salisbury, Joseph P; Vahabzadeh, Arshya; Sahin, Ned T

2017-01-01

Autism spectrum disorder (ASD) is a childhood-onset neurodevelopmental disorder with a rapidly rising prevalence, currently affecting 1 in 68 children, and over 3.5 million people in the United States. Current ASD interventions are primarily based on in-person behavioral therapies that are both costly and difficult to access. These interventions aim to address some of the fundamental deficits that clinically characterize ASD, including deficits in social communication, and the presence of stereotypies, and other autism-related behaviors. Current diagnostic and therapeutic approaches seldom rely on quantitative data measures of symptomatology, severity, or condition trajectory. Given the current situation, we report on the Brain Power System (BPS), a digital behavioral aid with quantitative data gathering and reporting features. The BPS includes customized smartglasses, providing targeted personalized coaching experiences through a family of gamified augmented-reality applications utilizing artificial intelligence. These applications provide children and adults with coaching for emotion recognition, face directed gaze, eye contact, and behavioral self-regulation. This preliminary case report, part of a larger set of upcoming research reports, explores the feasibility of the BPS to provide coaching in two boys with clinically diagnosed ASD, aged 8 and 9 years. The coaching intervention was found to be well tolerated and rated as being both engaging and fun. Both males could easily use the system, and no technical problems were noted. During the intervention, caregivers reported improved non-verbal communication, eye contact, and social engagement during the intervention. Both boys demonstrated decreased symptoms of ASD, as measured by the aberrant behavior checklist at 24-h post-intervention. Specifically, both cases demonstrated improvements in irritability, lethargy, stereotypy, hyperactivity/non-compliance, and inappropriate speech. Smartglasses using augmented reality may have an important future role in helping address the therapeutic needs of children with ASD. Quantitative data gathering from such sensor-rich systems may allow for digital phenotyping and the refinement of social communication constructs of the research domain criteria. This report provides evidence for the feasibility, usability, and tolerability of one such specialized smartglasses system.

External closed-circuit cooling system for management of patients after device implantation: A feasibility study.

PubMed

Giofrè, Fabrizio; Ferrari, Paola; Leidi, Cristina; Foschi, Maria Laura; Senni, Michele; De Filippo, Paolo

2017-08-15

In the first 24h after pacemaker or implantable cardioverter/defibrillator (ICD) implantation or replacement, the occurrence of hematoma and pain in the surgically treated region is not infrequent and may result in re-intervention and/or more severe complications, such as infections. Currently, the post-implant phase management is very empiric. The aim of this study was to test the clinical applicability and usefulness of an external close-circuit cooling system for the management of the early post-implant period in patients with high risk of hematoma due to anticoagulant and/or antiplatelet therapy. We studied 135 patients (78M; 71±11years) with high risk of hematoma occurrence after pace-maker (63 patients) or ICD (72 patients) implantation or replacement. Immediately after the intervention, a closed-circuit cooling system (CAREPACE™ system, Zamar, Italy) was externally applied on the pre-pectoral region to each patient and maintained for 24h. The system has a compressive pad and a refrigerating circuit in which non-toxic glycolic fluid is pumped. The fluid temperature was set and kept at 5°C for the whole period. The compressive and cooling effect of the system was well tolerated by all the patients at the temperature set. Four patients complained of noise due to machine operation, but in none the treatment was interrupted. The average length of hospital stay was 2.8±0.4days. No clinically significant hematoma was observed at discharge and after one month follow-up visit. This new system can be used for the management of the early phase after device implantation or replacement and appears clinically useful and well tolerated. Further studies on a larger scale are needed to test the potential reduction of post-intervention complications and the cost-effectiveness of this device. Copyright © 2017 Elsevier B.V. All rights reserved.

An exploration of clinical interventions provided by pharmacists within a complex asthma service

PubMed Central

Lemay, Kate S.; Saini, Bandana; Bosnic-Anticevich, Sinthia; Smith, Lorraine; Stewart, Kay; Emmerton, Lynne; Burton, Deborah L.; Krass, Ines; Armour, Carol L.

2014-01-01

Background: Pharmacists in Australia are accessible health care professionals, and their provision of clinical pharmacy interventions in a range of areas has been proven to improve patient outcomes. Individual clinical pharmacy interventions in the area of asthma management have been very successful. An understanding of the nature of these interventions will inform future pharmacy services. What we do not know is when pharmacists provide a complex asthma service, what elements of that service (interventions) they choose to deliver. Objective: To explore the scope and frequency of asthma-related clinical interventions provided by pharmacists to patients in an evidence-based complex asthma service. Methods: Pharmacists from 4 states/territories of Australia were trained in asthma management. People with asthma had 3 or 4 visits to the pharmacy. Guided by a structured patient file, the pharmacist assessed the patient’s asthma and management and provided interventions where and when considered appropriate, based on their clinical decision making skills. The interventions were recorded in a checklist in the patient file. They were then analysed descriptively and thematically. Results: Pharmacists provided 22,909 clinical pharmacy interventions over the service to 570 patients (398 of whom completed the service). The most frequently delivered interventions were in the themes ’Education on asthma’, ’Addressing trigger factors’, ’Medications - safe and effective use’ and ’Explore patient perspectives’. The patients had a high and ongoing need for interventions. Pharmacists selected interventions based on their assessment of perceived need then revisited and reinforced these interventions. Conclusion: Pharmacists identified a number of areas in which patients required interventions to assist with their asthma management. Many of these were perceived to require continuing reinforcement over the duration of the service. Pharmacists were able to use their clinical judgement to assess patients and provide clinical pharmacy interventions across a range of asthma management needs. PMID:25883692

Adaptation and translation of mental health interventions in Middle Eastern Arab countries: a systematic review of barriers to and strategies for effective treatment implementation.

PubMed

Gearing, Robin E; Schwalbe, Craig S; MacKenzie, Michael J; Brewer, Kathryne B; Ibrahim, Rawan W; Olimat, Hmoud S; Al-Makhamreh, Sahar S; Mian, Irfan; Al-Krenawi, Alean

2013-11-01

All too often, efficacious psychosocial evidence-based interventions fail when adapted from one culture to another. International translation requires a deep understanding of the local culture, nuanced differences within a culture, established service practices, and knowledge of obstacles and promoters to treatment implementation. This research investigated the following objectives to better facilitate cultural adaptation and translation of psychosocial and mental health treatments in Arab countries: (1) identify barriers or obstacles; (2) identify promoting strategies; and (3) provide clinical and research recommendations. This systematic review of 22 psychosocial or mental health studies in Middle East Arab countries identified more barriers (68%) than promoters (32%) to effective translation and adaptation of empirically supported psychosocial interventions. Identified barriers include obstacles related to acceptability of the intervention within the cultural context, community and system difficulties, and problems with clinical engagement processes. Whereas identified promoter strategies centre on the importance of partnering and working within the local and cultural context, the need to engage with acceptable and traditional intervention characteristics, and the development of culturally appropriate treatment strategies and techniques. Although Arab cultures across the Middle East are unique, this article provides a series of core clinical and research recommendations to assist effective treatment adaptation and translation within Arab communities in the Middle East.

Physician medical direction and clinical performance at an established emergency medical services system.

PubMed

Munk, Marc-David; White, Shaun D; Perry, Malcolm L; Platt, Thomas E; Hardan, Mohammed S; Stoy, Walt A

2009-01-01

Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001). We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.

Using electronic clinical practice audits as needs assessment to produce effective continuing medical education programming.

PubMed

Klein, Doug; Staples, John; Pittman, Carmen; Stepanko, Cheryl

2012-01-01

The traditional needs assessment used in developing continuing medical education programs typically relies on surveying physicians and tends to only capture perceived learning needs. Instead, using tools available in electronic medical record systems to perform a clinical audit on a physician's practice highlights physician-specific practice patterns. The purpose of this study was to test the feasibility of implementing an electronic clinical audit needs assessment process for family physicians in Canada. A clinical audit of 10 preventative care interventions and 10 chronic disease interventions was performed on family physician practices in Alberta, Canada. The physicians used the results from the audit to produce personalized learning needs, which were then translated into educational programming. A total of 26 family practices and 4489 patient records were audited. Documented completion rates for interventions ranged from 13% for ensuring a patient's tetanus vaccine is current to 97% of pregnant patients receiving the recommended prenatal vitamins. Electronic medical record-based needs assessments may provide a better basis for developing continuing medical education than a more traditional survey-based needs assessment. This electronic needs assessment uses the physician's own patient outcome information to assist in determining learning objectives that reflect both perceived and unperceived needs.

How to use concept mapping to identify barriers and facilitators of an electronic quality improvement intervention.

PubMed

van Engen-Verheul, Mariëtte; Peek, Niels; Vromen, Tom; Jaspers, Monique; de Keizer, Nicolette

2015-01-01

Systematic quality improvement (QI) interventions are increasingly used to change complex health care systems. Results of randomized clinical trials can provide quantitative evidence whether QI interventions were effective but they do not teach us why and how QI was (not) achieved. Qualitative research methods can answer these questions but typically involve only a small group of respondents against high resources. Concept mapping methodology overcomes these drawbacks by integrating results from qualitative group sessions with multivariate statistical analysis to represent ideas of diverse stakeholders visually on maps in an efficient way. This paper aims to describe how to use concept mapping to qualitatively gain insight into barriers and facilitators of an electronic QI intervention and presents experiences with the method from an ongoing case study to evaluate a QI system in the field of cardiac rehabilitation in the Netherlands.

Therapeutic interventions in sepsis: current and anticipated pharmacological agents

PubMed Central

Shukla, Prashant; Rao, G Madhava; Pandey, Gitu; Sharma, Shweta; Mittapelly, Naresh; Shegokar, Ranjita; Mishra, Prabhat Ranjan

2014-01-01

Sepsis is a clinical syndrome characterized by a multisystem response to a pathogenic assault due to underlying infection that involves a combination of interconnected biochemical, cellular and organ–organ interactive networks. After the withdrawal of recombinant human-activated protein C (rAPC), researchers and physicians have continued to search for new therapeutic approaches and targets against sepsis, effective in both hypo- and hyperinflammatory states. Currently, statins are being evaluated as a viable option in clinical trials. Many agents that have shown favourable results in experimental sepsis are not clinically effective or have not been clinically evaluated. Apart from developing new therapeutic molecules, there is great scope for for developing a variety of drug delivery strategies, such as nanoparticulate carriers and phospholipid-based systems. These nanoparticulate carriers neutralize intracorporeal LPS as well as deliver therapeutic agents to targeted tissues and subcellular locations. Here, we review and critically discuss the present status and new experimental and clinical approaches for therapeutic intervention in sepsis. PMID:24977655

Glycemic modulation in neuro-oncology: experience and future directions using a modified Atkins diet for high-grade brain tumors

PubMed Central

Strowd, Roy E.; Cervenka, Mackenzie C.; Henry, Bobbie J.; Kossoff, Eric H.; Hartman, Adam L.; Blakeley, Jaishri O.

2015-01-01

Dietary glycemic modulation through high-fat, low-carbohydrate diets, which induce a state of systemic ketosis and alter systemic metabolic signaling, have been incorporated into the clinical management of patients with neurological disease for more than a century. Mounting preclinical evidence supports the antitumor, proapoptotic, and antiangiogenic effects of disrupting glycolytic metabolism through dietary intervention. In recent years, interest in incorporating such novel therapeutic strategies in neuro-oncology has increased. To date, 3 published studies incorporating novel dietary therapies in oncology have been reported, including one phase I study in neuro-oncology, and have set the stage for further study in this field. In this article, we review the biochemical pathways, preclinical data, and early clinical translation of dietary interventions that modulate systemic glycolytic metabolism in the management of primary malignant brain tumors. We introduce the modified Atkins diet (MAD), a novel dietary alternative to the classic ketogenic diet, and discuss the critical issues facing future study. PMID:26649186

Payer view of personalized medicine.

PubMed

Pezalla, Edmund J

2016-12-01

The process and methods used by payers when evaluating coverage of personalized medicine testing are described. Personalized medicine encompasses a number of diagnostic tools that measure drug metabolism, genetic risk for disease development, and tumor type or markers that can guide oncology treatments. However, whole genome testing, tumor marker testing, and testing for drug metabolism are additional costs to the healthcare system. In order to justify these costs, payers and health technology assessment bodies must evaluate the individual tests or groups of tests on their own merits. In order for a test to be covered by payers, test developers must demonstrate clinical utility as measured by improved outcomes or well-informed decision-making. In the United States, payers generally focus on clinical benefit to individual patients and benefits to the healthcare system. Clinical benefits include improved outcomes. Benefits to the healthcare system are generally considered to be cost offsets, which may be due to reductions in the use of unnecessary interventions or to more efficient use of resources. Provider organizations have been assuming more responsibility and liability for healthcare costs through various risk arrangements, including accountable care organizations and patient-centered medical homes. Diagnostic tests that increase efficiency, reduce unnecessary interventions, and improve outcomes will be chosen by specialists in provider organizations. For personalized medicine approaches to be adopted and covered by health plans, the methods must be shown to be analytically and clinically valid and provide clinical utility at a reasonable level of cost-effectiveness to payers. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

A Two-Week Psychosocial Intervention Reduces Future Aggression and Incarceration in Clinically Aggressive Juvenile Offenders.

PubMed

Kendall, Ashley D; Emerson, Erin M; Hartmann, William E; Zinbarg, Richard E; Donenberg, Geri R

2017-12-01

There is a largely unmet need for evidence-based interventions that reduce future aggression and incarceration in clinically aggressive juvenile offenders serving probation. We addressed this gap using a group randomized controlled trial. Offenders both with and without clinical aggression were included, enabling comparison of intervention effects. Juveniles 13 to 17 years old (N = 310, mean = 16 years, 90% African-American, 66% male) on probation were assigned to a 2-week intervention targeting psychosocial factors implicated in risky behavior (e.g., learning strategies to manage "hot" emotions that prompt risk taking) or to an equally intensive health promotion control. Participants completed aggression measures at baseline, 6-, and 12-month follow-up and reported on incarceration at 12 months. Spline regression tested symptom change. Among clinically aggressive offenders (n = 71), the intervention arm showed significantly greater reductions in aggression over the first 6 months compared with controls. Juveniles from the intervention no longer met clinical criteria, on average, but clinically significant symptoms persisted in the control group. By 12 months, participants from the intervention appeared to maintain treatment gains, but their symptom levels no longer differed significantly from those in the control. However, the intervention group was nearly 4 times less likely than controls to report incarceration. Intervention effects were significantly stronger for offenders with clinical than with nonclinical (n = 239) baseline aggression. A 2-week intervention expedited improvements in aggression and reduced incarceration in clinically aggressive juvenile offenders. The findings underscore the importance of directing intervention resources to the most aggressive youth. Clinical trial registration information-PHAT Life: Preventing HIV/AIDS Among Teens in Juvenile Justice (PHAT Life); http://clinicaltrials.gov/; NCT02647710. Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.

Advancements in Magnetic Resonance–Guided Robotic Interventions in the Prostate

PubMed Central

Macura, Katarzyna J.; Stoianovici, Dan

2011-01-01

Magnetic resonance imaging (MRI) provides more detailed anatomical images of the prostate compared with the transrectal ultrasound imaging. Therefore, for the purpose of intervention in the prostate gland, diagnostic or therapeutic, MRI guidance offers a possibility of more precise targeting that may be crucial to the success of prostate interventions. However, access within the scanner is limited for manual instrument handling and the MR environment is most demanding among all imaging equipment with respect to the instrumentation used. A solution to this problem is the use of MR-compatible robots purposely designed to operate in the space and environmental restrictions inside the MR scanner allowing real-time interventions. Building an MRI-compatible robot is a very challenging engineering task because, in addition to the material restrictions that MRI instruments have, the robot requires actuators and sensors that limit the type of energies that can be used. Several important design problems have to be overcome before a successful MR-compatible robot application can be built. A number of MR-compatible robots, ranging from a simple manipulator to a fully automated system, have been developed, proposing ingenious solutions to the design challenge. Several systems have been already tested clinically for prostate biopsy and brachytherapy. As technology matures, precise image guidance for prostate interventions performed or assisted by specialized MR-compatible robotic devices may provide a uniquely accurate solution for guiding the intervention directly based on MR findings and feedback. Such an instrument would become a valuable clinical tool for biopsies directly targeting imaged tumor foci and delivering tumor-centered focal therapy. PMID:19512852

Acute Stroke and Obstruction of the Extracranial Carotid Artery Combined with Intracranial Tandem Occlusion: Results of Interventional Revascularization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lescher, Stephanie, E-mail: stephanie.lescher@kgu.de; Czeppan, Katja; Porto, Luciana

PurposeDue to high thrombus load, acute stroke patients with tandem obstructions of the extra- and intracranial carotid arteries or the middle cerebral artery show a very limited response to systemic thrombolysis. Interventional treatment with mechanical thrombectomy—often in combination with acute stenting of underlying atherosclerotic stenosis or dissection—is increasingly used. It has been shown that such complex interventions are technically feasible. The lack of optimal management strategies and clinical data encouraged us to review our acute stroke interventions in patient with anterior circulation tandem lesions to determine lesion patterns, interventional approaches, and angiographic or clinical outcomes.Patients and MethodsWe retrospectively analyzed amore » series of 39 consecutive patients with intracranial vessel occlusion of the anterior circulation simultaneously presenting with high-grade cervical internal carotid artery (ICA) stenosis or occlusion.ResultsEmergency ICA stent implantation was technically feasible in all patients, and intracranial recanalization with TICI ≥ 2b was reached in a large number of patients (64 %). Good clinical outcomes (mRS ≤ 2 at 3 months) were achieved in one third of the patients (36 %). Symptomatic hemorrhages occurred in four patients (10 %). Mortality was 10 %.ConclusionEndovascular recanalization of acute cervical carotid artery occlusion was technically feasible in all patients, and resulted in high extra- and intracranial revascularization rates. A trend for favorable clinical outcome was seen in a higher TICI score, younger age, good collateral status, and combined IV rTPA and endovascular therapy.« less

Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system.

PubMed

Grant, Richard W; Uratsu, Connie S; Estacio, Karen R; Altschuler, Andrea; Kim, Eileen; Fireman, Bruce; Adams, Alyce S; Schmittdiel, Julie A; Heisler, Michele

2016-03-01

Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system. This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015-6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) navigating research vs. quality improvement requirements; (2) addressing informed consent considerations; and (3) introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for "self-learning health system" research. By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations. Copyright © 2016 Elsevier Inc. All rights reserved.

Low Response of Renin-Angiotensin System to Sodium Intake Intervention in Chinese Hypertensive Patients.

PubMed

Feng, Weijing; Cai, Qingqing; Yuan, Woliang; Liu, Yu; Bardeesi, Adham Sameer A; Wang, Jingfeng; Chen, Jie; Huang, Hui

2016-02-01

The interactions of sodium balance and response of renin-angiotensin-aldosterone system are important for maintaining the hemodynamic stability in physiological conditions. However, the influence of short-term sodium intake intervention in the response of renin-angiotensin system (RAS) on hypertensive patients is still unclear. Thus, we conducted a clinical trial to investigate the effects of short-term sodium intake intervention on the response of RAS in hypertensive patients.One hundred twenty-five primary Chinese hypertensive patients were divided into high, moderate, and low sodium groups by 24-hour urinary sodium excretion (UNa). All the patients received a 10-day dietary sodium intake intervention with standardized sodium (173.91mmol/day) and potassium (61.53mmol/day). Blood pressure, urinary sodium, urinary potassium, plasma sodium, potassium, creatinine, the levels of plasma renin activity, plasma angiotensin II concentrations (AT-II), and plasma aldosterone concentrations were detected before and after the intervention.Before the intervention, no differences were found in blood pressure and RAS among 3 groups. After standardized dietary sodium intake intervention, both UNa excretion and systolic pressure decreased in high-sodium group, while they increased in moderate and low-sodium groups. Intriguingly, there were no changes in the levels of plasma renin activity, AT-II, and plasma aldosterone concentrations among 3 groups during the intervention.The present study demonstrated that the influenced sodium excretion and blood pressure by short-term sodium intake intervention were independent of RAS quick response in Chinese hypertensive patients.

Low Response of Renin–Angiotensin System to Sodium Intake Intervention in Chinese Hypertensive Patients

PubMed Central

Feng, Weijing; Cai, Qingqing; Yuan, Woliang; Liu, Yu; Bardeesi, Adham Sameer A.; Wang, Jingfeng; Chen, Jie; Huang, Hui

2016-01-01

Abstract The interactions of sodium balance and response of renin–angiotensin–aldosterone system are important for maintaining the hemodynamic stability in physiological conditions. However, the influence of short-term sodium intake intervention in the response of renin–angiotensin system (RAS) on hypertensive patients is still unclear. Thus, we conducted a clinical trial to investigate the effects of short-term sodium intake intervention on the response of RAS in hypertensive patients. One hundred twenty-five primary Chinese hypertensive patients were divided into high, moderate, and low sodium groups by 24-hour urinary sodium excretion (UNa+). All the patients received a 10-day dietary sodium intake intervention with standardized sodium (173.91mmol/day) and potassium (61.53mmol/day). Blood pressure, urinary sodium, urinary potassium, plasma sodium, potassium, creatinine, the levels of plasma renin activity, plasma angiotensin II concentrations (AT-II), and plasma aldosterone concentrations were detected before and after the intervention. Before the intervention, no differences were found in blood pressure and RAS among 3 groups. After standardized dietary sodium intake intervention, both UNa+ excretion and systolic pressure decreased in high-sodium group, while they increased in moderate and low-sodium groups. Intriguingly, there were no changes in the levels of plasma renin activity, AT-II, and plasma aldosterone concentrations among 3 groups during the intervention. The present study demonstrated that the influenced sodium excretion and blood pressure by short-term sodium intake intervention were independent of RAS quick response in Chinese hypertensive patients. PMID:26871780

Physician perspectives on a tailored multifaceted primary care practice facilitation intervention for improvement of cardiovascular care.

PubMed

Liddy, Clare; Singh, Jatinderpreet; Guo, Merry; Hogg, William

2016-02-01

Practice facilitation is an effective way to help physicians implement change in their clinics, but little is known about physicians' perspectives on this service. To examine physicians' responses to a practice facilitation program, focussing on their overall satisfaction, perceived most significant clinical changes, and interactions with the facilitator. The Improved Delivery of Cardiovascular Care program investigated the impact of practice facilitation on improving the quality of cardiovascular primary care in Eastern Ontario, Canada, from 2007 to 2011. We conducted a qualitative content analysis of post-intervention surveys completed by participating physicians, using a constant comparison approach framed around the Chronic Care Model. Ninety-five physicians completed the survey. Physicians overwhelmingly viewed the program positively, though descriptions of its benefits and impact varied widely. Facilitators filled three key roles for physicians, acting as a resource centre, motivator and outside perspective. Physicians adopted a number of changes in their practices. These changes include adoption of clinical information systems (diabetes registries), decision support tools (chart audits, guideline documents, flow sheets) and delivery system design (community resources). Most physicians appreciated having access to a practice facilitator and viewed the intervention positively. Insight into physicians' perspectives on practice facilitation provides a valuable counterpoint to outcomes-based evaluations of such services. Further research should investigate potential obstacles in the group of physicians who make fewer practice changes, as well as the sustainability of this type of facilitation intervention. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Interventional multispectral photoacoustic imaging with a clinical linear array ultrasound probe for guiding nerve blocks

NASA Astrophysics Data System (ADS)

Xia, Wenfeng; West, Simeon J.; Nikitichev, Daniil I.; Ourselin, Sebastien; Beard, Paul C.; Desjardins, Adrien E.

2016-03-01

Accurate identification of tissue structures such as nerves and blood vessels is critically important for interventional procedures such as nerve blocks. Ultrasound imaging is widely used as a guidance modality to visualize anatomical structures in real-time. However, identification of nerves and small blood vessels can be very challenging, and accidental intra-neural or intra-vascular injections can result in significant complications. Multi-spectral photoacoustic imaging can provide high sensitivity and specificity for discriminating hemoglobin- and lipid-rich tissues. However, conventional surface-illumination-based photoacoustic systems suffer from limited sensitivity at large depths. In this study, for the first time, an interventional multispectral photoacoustic imaging (IMPA) system was used to image nerves in a swine model in vivo. Pulsed excitation light with wavelengths in the ranges of 750 - 900 nm and 1150 - 1300 nm was delivered inside the body through an optical fiber positioned within the cannula of an injection needle. Ultrasound waves were received at the tissue surface using a clinical linear array imaging probe. Co-registered B-mode ultrasound images were acquired using the same imaging probe. Nerve identification was performed using a combination of B-mode ultrasound imaging and electrical stimulation. Using a linear model, spectral-unmixing of the photoacoustic data was performed to provide image contrast for oxygenated and de-oxygenated hemoglobin, water and lipids. Good correspondence between a known nerve location and a lipid-rich region in the photoacoustic images was observed. The results indicate that IMPA is a promising modality for guiding nerve blocks and other interventional procedures. Challenges involved with clinical translation are discussed.

Impact of Patient Reminders on Papanicolaou Test Completion for High-Risk Patients Identified by a Clinical Decision Support System.

PubMed

MacLaughlin, Kathy L; Kessler, Maya E; Komandur Elayavilli, Ravikumar; Hickey, Branden C; Scheitel, Marianne R; Wagholikar, Kavishwar B; Liu, Hongfang; Kremers, Walter K; Chaudhry, Rajeev

2018-05-01

A clinical decision support system (CDSS) for cervical cancer screening identifies patients due for routine cervical cancer screening. Yet, high-risk patients who require more frequent screening or earlier follow-up to address past abnormal results are not identified. We aimed to assess the effect of a complex CDSS, incorporating national guidelines for high-risk patient screening and abnormal result management, its implementation to identify patients overdue for testing, and the outcome of sending a targeted recommendation for follow-up. At three primary care clinics affiliated with an academic medical center, a reminder recommending an appointment for Papanicolaou (Pap) testing or Pap and human papillomavirus cotesting was sent to high-risk women aged 18 through 65 years (intervention group) identified by CDSS as overdue for testing. Historical control patients, who did not receive a reminder, were identified by CDSS 1 year before the date when reminders were sent to the intervention group. Test completion rates were compared between the intervention and control groups through a generalized estimating equation extension. Across the three sites, the average completion rate of recommended follow-up testing was significantly higher in the intervention group at 23.7% (61/257) than the completion rate at 3.3% (17/516) in the control group (p < 0.001). A CDSS with enhanced capabilities to identify high-risk women due for cervical cancer testing beyond routine screening intervals, with subsequent patient notification, has the potential to decrease cervical precancer and cancer by improving adherence to guideline-compliant follow-up and needed treatment.

Clinical pharmacy in a multidisciplinar team for chronic pain in adults.

PubMed

Bauters, T G M; Devulder, J; Robays, H

2008-01-01

The aim of this study was to evaluate the role and the impact of a clinical pharmacist as a member of a multidisciplinary pain team. Although physicians have a good knowledge of pharmacotherapy in the field of pain medication, pharmacy interventions were necessary to enhance the quality of prescribing. On a population of 93 patients, a total of 120 interventions were recorded. The different types of interventions included: provision of information (10.0%), clinical intervention (89.2%) and the provision of a specific product (0.8%). Out of the 107 clinical interventions, a total of 95.3 % interventions were accepted by the physicians. The results highlight the clinical importance of the pharmacy in optimizing drug therapy for adult patients with chronic pain.

Systematic data ingratiation of clinical trial recruitment locations for geographic-based query and visualization

PubMed Central

Luo, Jake; Chen, Weiheng; Wu, Min; Weng, Chunhua

2018-01-01

Background Prior studies of clinical trial planning indicate that it is crucial to search and screen recruitment sites before starting to enroll participants. However, currently there is no systematic method developed to support clinical investigators to search candidate recruitment sites according to their interested clinical trial factors. Objective In this study, we aim at developing a new approach to integrating the location data of over one million heterogeneous recruitment sites that are stored in clinical trial documents. The integrated recruitment location data can be searched and visualized using a map-based information retrieval method. The method enables systematic search and analysis of recruitment sites across a large amount of clinical trials. Methods The location data of more than 1.4 million recruitment sites of over 183,000 clinical trials was normalized and integrated using a geocoding method. The integrated data can be used to support geographic information retrieval of recruitment sites. Additionally, the information of over 6000 clinical trial target disease conditions and close to 4000 interventions was also integrated into the system and linked to the recruitment locations. Such data integration enabled the construction of a novel map-based query system. The system will allow clinical investigators to search and visualize candidate recruitment sites for clinical trials based on target conditions and interventions. Results The evaluation results showed that the coverage of the geographic location mapping for the 1.4 million recruitment sites was 99.8%. The evaluation of 200 randomly retrieved recruitment sites showed that the correctness of geographic information mapping was 96.5%. The recruitment intensities of the top 30 countries were also retrieved and analyzed. The data analysis results indicated that the recruitment intensity varied significantly across different countries and geographic areas. Conclusion This study contributed a new data processing framework to extract and integrate the location data of heterogeneous recruitment sites from clinical trial documents. The developed system can support effective retrieval and analysis of potential recruitment sites using target clinical trial factors. PMID:29132636

Systematic data ingratiation of clinical trial recruitment locations for geographic-based query and visualization.

PubMed

Luo, Jake; Chen, Weiheng; Wu, Min; Weng, Chunhua

2017-12-01

Prior studies of clinical trial planning indicate that it is crucial to search and screen recruitment sites before starting to enroll participants. However, currently there is no systematic method developed to support clinical investigators to search candidate recruitment sites according to their interested clinical trial factors. In this study, we aim at developing a new approach to integrating the location data of over one million heterogeneous recruitment sites that are stored in clinical trial documents. The integrated recruitment location data can be searched and visualized using a map-based information retrieval method. The method enables systematic search and analysis of recruitment sites across a large amount of clinical trials. The location data of more than 1.4 million recruitment sites of over 183,000 clinical trials was normalized and integrated using a geocoding method. The integrated data can be used to support geographic information retrieval of recruitment sites. Additionally, the information of over 6000 clinical trial target disease conditions and close to 4000 interventions was also integrated into the system and linked to the recruitment locations. Such data integration enabled the construction of a novel map-based query system. The system will allow clinical investigators to search and visualize candidate recruitment sites for clinical trials based on target conditions and interventions. The evaluation results showed that the coverage of the geographic location mapping for the 1.4 million recruitment sites was 99.8%. The evaluation of 200 randomly retrieved recruitment sites showed that the correctness of geographic information mapping was 96.5%. The recruitment intensities of the top 30 countries were also retrieved and analyzed. The data analysis results indicated that the recruitment intensity varied significantly across different countries and geographic areas. This study contributed a new data processing framework to extract and integrate the location data of heterogeneous recruitment sites from clinical trial documents. The developed system can support effective retrieval and analysis of potential recruitment sites using target clinical trial factors. Copyright © 2017 Elsevier B.V. All rights reserved.

A Triadic Neurocognitive Approach to Addiction for Clinical Interventions

PubMed Central

Noël, Xavier; Brevers, Damien; Bechara, Antoine

2013-01-01

According to the triadic neurocognitive model of addiction to drugs (e.g., cocaine) and non-drugs (e.g., gambling), weakened “willpower” associated with these behaviors is the product of an abnormal functioning in one or more of three key neural and cognitive systems: (1) an amygdala-striatum dependent system mediating automatic, habitual, and salient behaviors; (2) a prefrontal cortex dependent system important for self-regulation and forecasting the future consequences of a behavior; and (3) an insula dependent system for the reception of interoceptive signals and their translation into feeling states (such as urge and craving), which in turn plays a strong influential role in decision-making and impulse control processes related to uncertainty, risk, and reward. The described three-systems account for poor decision-making (i.e., prioritizing short-term consequences of a decisional option) and stimulus-driven actions, thus leading to a more elevated risk for relapse. Finally, this article elaborates on the need for “personalized” clinical model-based interventions targeting interactions between implicit processes, interoceptive signaling, and supervisory function aimed at helping individuals become less governed by immediate situations and automatic pre-potent responses, and more influenced by systems involved in the pursuit of future valued goals. PMID:24409155

A pilot randomized controlled trial of EKG for neonatal resuscitation

PubMed Central

Katheria, Anup; Arnell, Kathy; Brown, Melissa; Hassen, Kasim; Maldonado, Mauricio; Finer, Neil

2017-01-01

Background The seventh edition of the American Academy of Pediatrics Neonatal Resuscitation Program recommends the use of a cardiac monitor in infants that need resuscitation. Previous trials have shown that EKG heart rate is available before pulse rate from a pulse oximeter. To date no trial has looked at how the availability of electrocardiogram (EKG) affects clinical interventions in the delivery room. Objective To determine whether the availability of an EKG heart rate value and tracing to the clinical team has an effect on physiologic measures and related interventions during the stabilization of preterm infants. Design/Methods Forty (40) premature infants enrolled in a neuro-monitoring study (The Neu-Prem Trial: NCT02605733) who had an EKG monitor available were randomized to have the heart rate information from the bedside EKG monitor either displayed or not displayed to the clinical team. Heart rate, oxygen saturation, FiO2 and mean airway pressure from a data acquisition system were recorded every 2 seconds. Results were averaged over 30 seconds and the differences analyzed using two-tailed t-test. Interventions analyzed included time to first change in FiO2, first positive pressure ventilation, first increase in airway pressure, and first intubation. Results There were no significant differences in time to clinical interventions between the blinded and unblinded group, despite the unblinded group having access to a visible heart rate at 66 +/- 20 compared to 114 +/- 39 seconds for the blinded group (p < .0001). Pulse rate from oximeter was lower than EKG heart rate during the first 2 minutes of life, but this was not significant. Conclusion(s) EKG provides an earlier, and more accurate heart rate than pulse rate from an oximeter during stabilization of preterm infants, allowing earlier intervention. All interventions were started earlier in the unblinded EKG group but these numbers were not significant in this small trial. Earlier EKG placement before pulse oximeter placement may affect other interventions, but this needs further study. PMID:29099872

Integrating Transgenic Vector Manipulation with Clinical Interventions to Manage Vector-Borne Diseases.

PubMed

Okamoto, Kenichi W; Gould, Fred; Lloyd, Alun L

2016-03-01

Many vector-borne diseases lack effective vaccines and medications, and the limitations of traditional vector control have inspired novel approaches based on using genetic engineering to manipulate vector populations and thereby reduce transmission. Yet both the short- and long-term epidemiological effects of these transgenic strategies are highly uncertain. If neither vaccines, medications, nor transgenic strategies can by themselves suffice for managing vector-borne diseases, integrating these approaches becomes key. Here we develop a framework to evaluate how clinical interventions (i.e., vaccination and medication) can be integrated with transgenic vector manipulation strategies to prevent disease invasion and reduce disease incidence. We show that the ability of clinical interventions to accelerate disease suppression can depend on the nature of the transgenic manipulation deployed (e.g., whether vector population reduction or replacement is attempted). We find that making a specific, individual strategy highly effective may not be necessary for attaining public-health objectives, provided suitable combinations can be adopted. However, we show how combining only partially effective antimicrobial drugs or vaccination with transgenic vector manipulations that merely temporarily lower vector competence can amplify disease resurgence following transient suppression. Thus, transgenic vector manipulation that cannot be sustained can have adverse consequences-consequences which ineffective clinical interventions can at best only mitigate, and at worst temporarily exacerbate. This result, which arises from differences between the time scale on which the interventions affect disease dynamics and the time scale of host population dynamics, highlights the importance of accounting for the potential delay in the effects of deploying public health strategies on long-term disease incidence. We find that for systems at the disease-endemic equilibrium, even modest perturbations induced by weak interventions can exhibit strong, albeit transient, epidemiological effects. This, together with our finding that under some conditions combining strategies could have transient adverse epidemiological effects suggests that a relatively long time horizon may be necessary to discern the efficacy of alternative intervention strategies.

Integrating Transgenic Vector Manipulation with Clinical Interventions to Manage Vector-Borne Diseases

PubMed Central

Okamoto, Kenichi W.; Gould, Fred; Lloyd, Alun L.

2016-01-01

Many vector-borne diseases lack effective vaccines and medications, and the limitations of traditional vector control have inspired novel approaches based on using genetic engineering to manipulate vector populations and thereby reduce transmission. Yet both the short- and long-term epidemiological effects of these transgenic strategies are highly uncertain. If neither vaccines, medications, nor transgenic strategies can by themselves suffice for managing vector-borne diseases, integrating these approaches becomes key. Here we develop a framework to evaluate how clinical interventions (i.e., vaccination and medication) can be integrated with transgenic vector manipulation strategies to prevent disease invasion and reduce disease incidence. We show that the ability of clinical interventions to accelerate disease suppression can depend on the nature of the transgenic manipulation deployed (e.g., whether vector population reduction or replacement is attempted). We find that making a specific, individual strategy highly effective may not be necessary for attaining public-health objectives, provided suitable combinations can be adopted. However, we show how combining only partially effective antimicrobial drugs or vaccination with transgenic vector manipulations that merely temporarily lower vector competence can amplify disease resurgence following transient suppression. Thus, transgenic vector manipulation that cannot be sustained can have adverse consequences—consequences which ineffective clinical interventions can at best only mitigate, and at worst temporarily exacerbate. This result, which arises from differences between the time scale on which the interventions affect disease dynamics and the time scale of host population dynamics, highlights the importance of accounting for the potential delay in the effects of deploying public health strategies on long-term disease incidence. We find that for systems at the disease-endemic equilibrium, even modest perturbations induced by weak interventions can exhibit strong, albeit transient, epidemiological effects. This, together with our finding that under some conditions combining strategies could have transient adverse epidemiological effects suggests that a relatively long time horizon may be necessary to discern the efficacy of alternative intervention strategies. PMID:26962871

Virtual reality in radiology: virtual intervention

NASA Astrophysics Data System (ADS)

Harreld, Michael R.; Valentino, Daniel J.; Duckwiler, Gary R.; Lufkin, Robert B.; Karplus, Walter J.

1995-04-01

Intracranial aneurysms are the primary cause of non-traumatic subarachnoid hemorrhage. Morbidity and mortality remain high even with current endovascular intervention techniques. It is presently impossible to identify which aneurysms will grow and rupture, however hemodynamics are thought to play an important role in aneurysm development. With this in mind, we have simulated blood flow in laboratory animals using three dimensional computational fluid dynamics software. The data output from these simulations is three dimensional, complex and transient. Visualization of 3D flow structures with standard 2D display is cumbersome, and may be better performed using a virtual reality system. We are developing a VR-based system for visualization of the computed blood flow and stress fields. This paper presents the progress to date and future plans for our clinical VR-based intervention simulator. The ultimate goal is to develop a software system that will be able to accurately model an aneurysm detected on clinical angiography, visualize this model in virtual reality, predict its future behavior, and give insight into the type of treatment necessary. An associated database will give historical and outcome information on prior aneurysms (including dynamic, structural, and categorical data) that will be matched to any current case, and assist in treatment planning (e.g., natural history vs. treatment risk, surgical vs. endovascular treatment risks, cure prediction, complication rates).

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study.

PubMed

Perron, Noelle Junod; Dao, Melissa Dominicé; Kossovsky, Michel P; Miserez, Valerie; Chuard, Carmen; Calmy, Alexandra; Gaspoz, Jean-Michel

2010-10-25

Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments. We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded. 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1 year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09). A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study

PubMed Central

2010-01-01

Background Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments. Methods We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded. Results 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09). Conclusion A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders. PMID:20973950

Improving public health information: a data quality intervention in KwaZulu-Natal, South Africa.

PubMed

Mphatswe, W; Mate, K S; Bennett, B; Ngidi, H; Reddy, J; Barker, P M; Rollins, N

2012-03-01

To evaluate the effect of an intervention to improve the quality of data used to monitor the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus in South Africa. The study involved 58 antenatal clinics and 20 delivery wards (37 urban, 21 rural and 20 semi-urban) in KwaZulu-Natal province that provided PMTCT services and reported data to the District Health Information System. The data improvement intervention, which was implemented between May 2008 and March 2009, involved training on data collection and feedback for health information personnel and programme managers, monthly data reviews and data audits at health-care facilities. Data on six data elements used to monitor PMTCT services and recorded in the information system were compared with source data from health facility registers before, during and after the intervention. Data completeness (i.e. their presence in the system) and accuracy (i.e. being within 10% of their true value) were evaluated. The level of data completeness increased from 26% before to 64% after the intervention. Similarly, the proportion of data in the information system considered accurate increased from 37% to 65% (P < 0.0001). Moreover, the correlation between data in the information system and those from facility registers rose from 0.54 to 0.92. A simple, practical data improvement intervention significantly increased the completeness and accuracy of the data used to monitor PMTCT services in South Africa.

Implementing a web-based home monitoring system within an academic health care network: barriers and facilitators to innovation diffusion.

PubMed

Pelletier, Alexandra C; Jethwani, Kamal; Bello, Heather; Kvedar, Joseph; Grant, Richard W

2011-01-01

The practice of outpatient type 2 diabetes management is gradually moving from the traditional visit-based, fee-for-service model to a new, health information communication technology (ICT)-supported model that can enable non-visit-based diabetes care. To date, adoption of innovative health ICT tools for diabetes management has been slowed by numerous barriers, such as capital investment costs, lack of reliable reimbursement mechanisms, design defects that have made some systems time-consuming and inefficient to use, and the need to integrate new ICT tools into a system not primarily designed for their use. Effective implementation of innovative diabetes health ICT interventions must address local practice heterogeneity and the interaction of this heterogeneity with clinical care delivery. The Center for Connected Health at Partners Healthcare has implemented a new ICT intervention, Diabetes Connect (DC), a Web-based glucose home monitoring and clinical messaging system. Using the framework of the diffusion of innovation theory, we review the implementation and examine lessons learned as we continue to deploy DC across the health care network. © 2010 Diabetes Technology Society.

Implementing a low-cost web-based clinical trial management system for community studies: a case study.

PubMed

Geyer, John; Myers, Kathleen; Vander Stoep, Ann; McCarty, Carolyn; Palmer, Nancy; DeSalvo, Amy

2011-10-01

Clinical trials with multiple intervention locations and a single research coordinating center can be logistically difficult to implement. Increasingly, web-based systems are used to provide clinical trial support with many commercial, open source, and proprietary systems in use. New web-based tools are available which can be customized without programming expertise to deliver web-based clinical trial management and data collection functions. To demonstrate the feasibility of utilizing low-cost configurable applications to create a customized web-based data collection and study management system for a five intervention site randomized clinical trial establishing the efficacy of providing evidence-based treatment via teleconferencing to children with attention-deficit hyperactivity disorder. The sites are small communities that would not usually be included in traditional randomized trials. A major goal was to develop database that participants could access from computers in their home communities for direct data entry. Discussed is the selection process leading to the identification and utilization of a cost-effective and user-friendly set of tools capable of customization for data collection and study management tasks. An online assessment collection application, template-based web portal creation application, and web-accessible Access 2007 database were selected and customized to provide the following features: schedule appointments, administer and monitor online secure assessments, issue subject incentives, and securely transmit electronic documents between sites. Each tool was configured by users with limited programming expertise. As of June 2011, the system has successfully been used with 125 participants in 5 communities, who have completed 536 sets of assessment questionnaires, 8 community therapists, and 11 research staff at the research coordinating center. Total automation of processes is not possible with the current set of tools as each is loosely affiliated, creating some inefficiency. This system is best suited to investigations with a single data source e.g., psychosocial questionnaires. New web-based applications can be used by investigators with limited programming experience to implement user-friendly, efficient, and cost-effective tools for multi-site clinical trials with small distant communities. Such systems allow the inclusion in research of populations that are not usually involved in clinical trials.

2D–3D radiograph to cone-beam computed tomography (CBCT) registration for C-arm image-guided robotic surgery

PubMed Central

Liu, Wen Pei; Otake, Yoshito; Azizian, Mahdi; Wagner, Oliver J.; Sorger, Jonathan M.; Armand, Mehran; Taylor, Russell H.

2015-01-01

Purpose C-arm radiographs are commonly used for intraoperative image guidance in surgical interventions. Fluoroscopy is a cost-effective real-time modality, although image quality can vary greatly depending on the target anatomy. Cone-beam computed tomography (CBCT) scans are sometimes available, so 2D–3D registration is needed for intra-procedural guidance. C-arm radiographs were registered to CBCT scans and used for 3D localization of peritumor fiducials during a minimally invasive thoracic intervention with a da Vinci Si robot. Methods Intensity-based 2D–3D registration of intraoperative radiographs to CBCT was performed. The feasible range of X-ray projections achievable by a C-arm positioned around a da Vinci Si surgical robot, configured for robotic wedge resection, was determined using phantom models. Experiments were conducted on synthetic phantoms and animals imaged with an OEC 9600 and a Siemens Artis zeego, representing the spectrum of different C-arm systems currently available for clinical use. Results The image guidance workflow was feasible using either an optically tracked OEC 9600 or a Siemens Artis zeego C-arm, resulting in an angular difference of Δθ : ~ 30°. The two C-arm systems provided TREmean ≤ 2.5 mm and TREmean ≤ 2.0 mm, respectively (i.e., comparable to standard clinical intraoperative navigation systems). Conclusions C-arm 3D localization from dual 2D–3D registered radiographs was feasible and applicable for intraoperative image guidance during da Vinci robotic thoracic interventions using the proposed workflow. Tissue deformation and in vivo experiments are required before clinical evaluation of this system. PMID:25503592

Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention.

PubMed

Taylor, Charles T; Lyubomirsky, Sonja; Stein, Murray B

2017-03-01

Research suggests that the positive affect system may be an important yet underexplored treatment target in anxiety and depression. Existing interventions primarily target the negative affect system, yielding modest effects on measures of positive emotions and associated outcomes (e.g., psychological well-being). The objective of the present pilot study was to evaluate the efficacy of a new transdiagnostic positive activity intervention (PAI) for anxiety and depression. Twenty-nine treatment-seeking individuals presenting with clinically impairing symptoms of anxiety and/or depression were randomly allocated to a 10-session protocol comprised of PAIs previously shown in nonclinical samples to improve positive thinking, emotions, and behaviors (e.g., gratitude, acts of kindness, optimism; n = 16) or a waitlist (WL) condition (n = 13). Participants were assessed at pre- and posttreatment, as well as 3- and 6-month follow-up, on measures of positive and negative affect, symptoms, and psychological well-being. ClinicalTrials.gov Identifier: NCT02330627 RESULTS: The PAI group displayed significantly larger improvements in positive affect and psychological well-being from pre- to posttreatment compared to WL. Posttreatment and follow-up scores in the PAI group were comparable to general population norms. The PAI regimen also resulted in significantly larger reductions in negative affect, as well as anxiety and depression symptoms, compared to WL. Improvements across all outcomes were large in magnitude and maintained over a 6-month follow-up period. Targeting the positive affect system through a multicomponent PAI regimen may be beneficial for generating improvements in positive emotions and well-being, as well as reducing negative affect and symptoms, in individuals with clinically impairing anxiety or depression. © 2016 Wiley Periodicals, Inc.

Harnessing neuroplasticity for clinical applications

PubMed Central

Sur, Mriganka; Dobkin, Bruce H.; O'Brien, Charles; Sanger, Terence D.; Trojanowski, John Q.; Rumsey, Judith M.; Hicks, Ramona; Cameron, Judy; Chen, Daofen; Chen, Wen G.; Cohen, Leonardo G.; deCharms, Christopher; Duffy, Charles J.; Eden, Guinevere F.; Fetz, Eberhard E.; Filart, Rosemarie; Freund, Michelle; Grant, Steven J.; Haber, Suzanne; Kalivas, Peter W.; Kolb, Bryan; Kramer, Arthur F.; Lynch, Minda; Mayberg, Helen S.; McQuillen, Patrick S.; Nitkin, Ralph; Pascual-Leone, Alvaro; Reuter-Lorenz, Patricia; Schiff, Nicholas; Sharma, Anu; Shekim, Lana; Stryker, Michael; Sullivan, Edith V.; Vinogradov, Sophia

2011-01-01

Neuroplasticity can be defined as the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections. Major advances in the understanding of neuroplasticity have to date yielded few established interventions. To advance the translation of neuroplasticity research towards clinical applications, the National Institutes of Health Blueprint for Neuroscience Research sponsored a workshop in 2009. Basic and clinical researchers in disciplines from central nervous system injury/stroke, mental/addictive disorders, paediatric/developmental disorders and neurodegeneration/ageing identified cardinal examples of neuroplasticity, underlying mechanisms, therapeutic implications and common denominators. Promising therapies that may enhance training-induced cognitive and motor learning, such as brain stimulation and neuropharmacological interventions, were identified, along with questions of how best to use this body of information to reduce human disability. Improved understanding of adaptive mechanisms at every level, from molecules to synapses, to networks, to behaviour, can be gained from iterative collaborations between basic and clinical researchers. Lessons can be gleaned from studying fields related to plasticity, such as development, critical periods, learning and response to disease. Improved means of assessing neuroplasticity in humans, including biomarkers for predicting and monitoring treatment response, are needed. Neuroplasticity occurs with many variations, in many forms, and in many contexts. However, common themes in plasticity that emerge across diverse central nervous system conditions include experience dependence, time sensitivity and the importance of motivation and attention. Integration of information across disciplines should enhance opportunities for the translation of neuroplasticity and circuit retraining research into effective clinical therapies. PMID:21482550

Cost effectiveness of adopted quality requirements in hospital laboratories.

PubMed

Hamza, Alneil; Ahmed-Abakur, Eltayib; Abugroun, Elsir; Bakhit, Siham; Holi, Mohamed

2013-01-01

The present study was designed in quasi-experiment to assess adoption of the essential clauses of particular clinical laboratory quality management requirements based on international organization for standardization (ISO 15189) in hospital laboratories and to evaluate the cost effectiveness of compliance to ISO 15189. The quality management intervention based on ISO 15189 was conceded through three phases; pre - intervention phase, Intervention phase and Post-intervention phase. In pre-intervention phase the compliance to ISO 15189 was 49% for study group vs. 47% for control group with P value 0.48, while the post intervention results displayed 54% vs. 79% for study group and control group respectively in compliance to ISO 15189 and statistically significant difference (P value 0.00) with effect size (Cohen's d) of (0.00) in pre-intervention phase and (0.99) in post - intervention phase. The annual average cost per-test for the study group and control group was 1.80 ± 0.25 vs. 1.97 ± 0.39, respectively with P value 0.39 whereas the post-intervention results showed that the annual average total costs per-test for study group and control group was 1.57 ± 0.23 vs 2.08 ± 0.38, P value 0.019 respectively, with cost-effectiveness ratio of (0.88) in pre -intervention phase and (0.52) in post-intervention phase. The planned adoption of quality management requirements (QMS) in clinical laboratories had great effect to increase the compliance percent with quality management system requirement, raise the average total cost effectiveness, and improve the analytical process capability of the testing procedure.

Methods to Evaluate the Effects of Internet-Based Digital Health Interventions for Citizens: Systematic Review of Reviews.

PubMed

Zanaboni, Paolo; Ngangue, Patrice; Mbemba, Gisele Irène Claudine; Schopf, Thomas Roger; Bergmo, Trine Strand; Gagnon, Marie-Pierre

2018-06-07

Digital health can empower citizens to manage their health and address health care system problems including poor access, uncoordinated care and increasing costs. Digital health interventions are typically complex interventions. Therefore, evaluations present methodological challenges. The objective of this study was to provide a systematic overview of the methods used to evaluate the effects of internet-based digital health interventions for citizens. Three research questions were addressed to explore methods regarding approaches (study design), effects and indicators. We conducted a systematic review of reviews of the methods used to measure the effects of internet-based digital health interventions for citizens. The protocol was developed a priori according to Preferred Reporting Items for Systematic review and Meta-Analysis Protocols and the Cochrane Collaboration methodology for overviews of reviews. Qualitative, mixed-method, and quantitative reviews published in English or French from January 2010 to October 2016 were included. We searched for published reviews in PubMed, EMBASE, The Cochrane Database of Systematic Reviews, CINHAL and Epistemonikos. We categorized the findings based on a thematic analysis of the reviews structured around study designs, indicators, types of interventions, effects and perspectives. A total of 20 unique reviews were included. The most common digital health interventions for citizens were patient portals and patients' access to electronic health records, covered by 10/20 (50%) and 6/20 (30%) reviews, respectively. Quantitative approaches to study design included observational study (15/20 reviews, 75%), randomized controlled trial (13/20 reviews, 65%), quasi-experimental design (9/20 reviews, 45%), and pre-post studies (6/20 reviews, 30%). Qualitative studies or mixed methods were reported in 13/20 (65%) reviews. Five main categories of effects were identified: (1) health and clinical outcomes, (2) psychological and behavioral outcomes, (3) health care utilization, (4) system adoption and use, and (5) system attributes. Health and clinical outcomes were measured with both general indicators and disease-specific indicators and reported in 11/20 (55%) reviews. Patient-provider communication and patient satisfaction were the most investigated psychological and behavioral outcomes, reported in 13/20 (65%) and 12/20 (60%) reviews, respectively. Evaluation of health care utilization was included in 8/20 (40%) reviews, most of which focused on the economic effects on the health care system. Although observational studies and surveys have provided evidence of benefits and satisfaction for patients, there is still little reliable evidence from randomized controlled trials of improved health outcomes. Future evaluations of digital health interventions for citizens should focus on specific populations or chronic conditions which are more likely to achieve clinically meaningful benefits and use high-quality approaches such as randomized controlled trials. Implementation research methods should also be considered. We identified a wide range of effects and indicators, most of which focused on patients as main end users. Implications for providers and the health system should also be included in evaluations or monitoring of digital health interventions. ©Paolo Zanaboni, Patrice Ngangue, Gisele Irène Claudine Mbemba, Thomas Roger Schopf, Trine Strand Bergmo, Marie-Pierre Gagnon. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.06.2018.

[Crisis Intervention in a Health Care Hospital for Child and Adolescent Psychiatry].

PubMed

Burchard, Falk; Diebenbusch, Teresa

2017-01-01

Crisis Intervention in a Health Care Hospital for Child and Adolescent Psychiatry In the past years the pressure in society and psychological problems in Germany have risen up. This can especially be verified by the great influx of utilization of child and adolescent psychiatric clinics through the admission of crisis. In this connection social disadvantaged female adolescents with a low socio-economic status, students of the secondary school, children in care and the ones whose parents have to manage their upbringing alone are preferentially affected. These developments require a fast adaptation of the supply system to the transformed demands, in particular in terms of outpatient treatment, as well as a closely and structured cooperation between the youth welfare and child and adolescent psychiatric clinics in their function as systems of help. In the script statistical data and adaptive approaches of a supply department of child and adolescent psychiatry are presented.

Remote magnetic actuation using a clinical scale system

PubMed Central

Stehning, Christian; Gleich, Bernhard

2018-01-01

Remote magnetic manipulation is a powerful technique for controlling devices inside the human body. It enables actuation and locomotion of tethered and untethered objects without the need for a local power supply. In clinical applications, it is used for active steering of catheters in medical interventions such as cardiac ablation for arrhythmia treatment and for steering of camera pills in the gastro-intestinal tract for diagnostic video acquisition. For these applications, specialized clinical-scale field applicators have been developed, which are rather limited in terms of field strength and flexibility of field application. For a general-purpose field applicator, flexible field generation is required at high field strengths as well as high field gradients to enable the generation of both torques and forces on magnetic devices. To date, this requirement has only been met by small-scale experimental systems. We have built a highly versatile clinical-scale field applicator that enables the generation of strong magnetic fields as well as strong field gradients over a large workspace. We demonstrate the capabilities of this coil-based system by remote steering of magnetic drills through gel and tissue samples with high torques on well-defined curved trajectories. We also give initial proof that, when equipped with high frequency transmit-receive coils, the machine is capable of real-time magnetic particle imaging while retaining a clinical-scale bore size. Our findings open the door for image-guided radiation-free remote magnetic control of devices at the clinical scale, which may be useful in minimally invasive diagnostic and therapeutic medical interventions. PMID:29494647

A Three-Phase Decision Model of Computer-Aided Coding for the Iranian Classification of Health Interventions (IRCHI)

PubMed Central

Azadmanjir, Zahra; Safdari, Reza; Ghazisaeedi, Marjan; Mokhtaran, Mehrshad; Kameli, Mohammad Esmail

2017-01-01

Introduction: Accurate coded data in the healthcare are critical. Computer-Assisted Coding (CAC) is an effective tool to improve clinical coding in particular when a new classification will be developed and implemented. But determine the appropriate method for development need to consider the specifications of existing CAC systems, requirements for each type, our infrastructure and also, the classification scheme. Aim: The aim of the study was the development of a decision model for determining accurate code of each medical intervention in Iranian Classification of Health Interventions (IRCHI) that can be implemented as a suitable CAC system. Methods: first, a sample of existing CAC systems was reviewed. Then feasibility of each one of CAC types was examined with regard to their prerequisites for their implementation. The next step, proper model was proposed according to the structure of the classification scheme and was implemented as an interactive system. Results: There is a significant relationship between the level of assistance of a CAC system and integration of it with electronic medical documents. Implementation of fully automated CAC systems is impossible due to immature development of electronic medical record and problems in using language for medical documenting. So, a model was proposed to develop semi-automated CAC system based on hierarchical relationships between entities in the classification scheme and also the logic of decision making to specify the characters of code step by step through a web-based interactive user interface for CAC. It was composed of three phases to select Target, Action and Means respectively for an intervention. Conclusion: The proposed model was suitable the current status of clinical documentation and coding in Iran and also, the structure of new classification scheme. Our results show it was practical. However, the model needs to be evaluated in the next stage of the research. PMID:28883671

Automatic cable artifact removal for cardiac C-arm CT imaging

NASA Astrophysics Data System (ADS)

Haase, C.; Schäfer, D.; Kim, M.; Chen, S. J.; Carroll, J.; Eshuis, P.; Dössel, O.; Grass, M.

2014-03-01

Cardiac C-arm computed tomography (CT) imaging using interventional C-arm systems can be applied in various areas of interventional cardiology ranging from structural heart disease and electrophysiology interventions to valve procedures in hybrid operating rooms. In contrast to conventional CT systems, the reconstruction field of view (FOV) of C-arm systems is limited to a region of interest in cone-beam (along the patient axis) and fan-beam (in the transaxial plane) direction. Hence, highly X-ray opaque objects (e.g. cables from the interventional setup) outside the reconstruction field of view, yield streak artifacts in the reconstruction volume. To decrease the impact of these streaks a cable tracking approach on the 2D projection sequences with subsequent interpolation is applied. The proposed approach uses the fact that the projected position of objects outside the reconstruction volume depends strongly on the projection perspective. By tracking candidate points over multiple projections only objects outside the reconstruction volume are segmented in the projections. The method is quantitatively evaluated based on 30 simulated CT data sets. The 3D root mean square deviation to a reference image could be reduced for all cases by an average of 50 % (min 16 %, max 76 %). Image quality improvement is shown for clinical whole heart data sets acquired on an interventional C-arm system.

Warfarin Management and Outcomes in Patients with Nonvalvular Atrial Fibrillation Within an Integrated Health Care System.

PubMed

An, JaeJin; Niu, Fang; Zheng, Chengyi; Rashid, Nazia; Mendes, Robert A; Dills, Diana; Vo, Lien; Singh, Prianka; Bruno, Amanda; Lang, Daniel T; Le, Paul T; Jazdzewski, Kristin P; Aranda, Gustavus

2017-06-01

Warfarin is a common treatment option to manage patients with nonvalvular atrial fibrillation (NVAF) in clinical practice. Understanding current pharmacist-led anticoagulation clinic management patterns and associated outcomes is important for quality improvement; however, currently little evidence associating outcomes with management patterns exists. To (a) describe warfarin management patterns and (b) evaluate associations between warfarin treatment and clinical outcomes for patients with NVAF in an integrated health care system. A retrospective cohort study was conducted among NVAF patients with warfarin therapy between January 1, 2006, and December 31, 2011, using Kaiser Permanente Southern California data, and followed until December 31, 2013. Management patterns related to international normalized ratio (INR) monitoring, anticoagulation clinic pharmacist intervention (consultation), and warfarin dose adjustments were investigated along with yearly attrition rates, time-in-therapeutic ranges (TTRs), and clinical outcomes (stroke or systemic embolism and major bleeding). Descriptive statistics and multivariable Cox proportional hazard models were used to determine associations between TTR and clinical outcomes. A total of 32,074 NVAF patients on warfarin treatment were identified and followed for a median of 3.8 years. About half (49%) of the patients were newly initiating warfarin therapy. INR monitoring and pharmacist interventions were conducted roughly every 3 weeks after 6 months of warfarin treatment. Sixty-three percent of the study population had ≥ 1 warfarin dose adjustments with a mean (SD) of 6.7 (6.3) annual dose adjustments. Warfarin dose adjustments occurred at a median of 1 day (interquartile ranges [IQR] 1-3) after the INR measurement. Yearly attrition rate was from 3.3% to 6.3% during the follow-up, and median (IQR) TTR was 61% (46%-73%). Patients who received frequent INR monitoring (≥ 27 times per year), pharmacist interventions (≥ 24 times per year), or frequently adjusted warfarin dose (≥ 11 times per year) consistently showed poor TTRs (mean TTR for the highest quartiles was 45.3%-48.3%). A higher TTR was associated with a lower risk of clinical outcomes regardless of frequency of INR monitoring, pharmacist interventions, or number of dose adjustments. Patients whose TTRs were < 65%, even with frequent pharmacist interventions, had similar stroke or systemic embolism event rates, as compared with patients with TTRs < 65% and less frequent interventions (1.88 vs. 1.54 stroke or systemic embolism rates per 100 person-years, respectively, P = 0.78). The lowest TTR quartile (< 46%) was associated with a 3 times higher risk of stroke or systemic embolism (hazard ratio [HR] = 3.19, 95% CI = 2.71-3.77) and a 2 times higher risk of major bleeding (HR = 2.10, 95% CI = 1.96-2.24) compared with the highest TTR quartile (≥ 73%). Despite close monitoring with timely warfarin dose adjustments, there were still a substantial number of challenging patients whose TTRs were suboptimal despite a higher number of pharmacist interventions. These patients eventually experienced more stroke or systemic embolism and bleeding events among NVAF patients managed by anticoagulation clinics. New individualized treatment or management strategies for patients who are not able to reach optimal therapeutic ranges are necessary to improve outcomes. This research and manuscript were funded by Bristol-Myers Squibb Company and Pfizer. Authors from Bristol-Myers Squibb Company and Pfizer participated in the design of the study, interpretation of the data, review/revision of the manuscript, and approval of the final version of the manuscript. An received a grant for research support from Bristol-Myers Squibb/Pfizer. Niu, Rashid, and Zheng received a grant from Bristol-Myers Squibb/Pfizer to their institutions for salary reimbursement. Vo, Singh, and Aranda are employed by Bristol-Myers Squibb; Bruno was employed by Bristol-Myers Squibb at the time of this study. Mendes and Dills are employed by Pfizer, and Mendes was a member of the Pfizer Cardiovascular and Metabolic Field Medical Team during the time of this study. Lang, Jazdzewski, and Le have no known conflicts of interest to report. Study concept and design were contributed primarily by An and Rashid, along with the other authors. Niu took the lead in data collection, along with Zheng, and data interpretation was performed by An, along with Mendes and Dills, with assistance from the other authors. The manuscript was written by An and revised by Mendes, Dills, Vo, Singh, Bruno, and Aranda, along with Lang, Le, and Jazdezewski. Part of this study's findings was presented at the CHEST 2015 Annual Meeting in Montreal, Canada, on October 28, 2015.

Designing an Intervention for Women with Systemic Lupus Erythematosus from Medically Underserved Areas to Improve Care: A Qualitative Study

PubMed Central

Feldman, Candace H; Bermas, Bonnie L; Zibit, Melanie; Fraser, Patricia; Todd, Derrick J; Fortin, Paul R; Massarotti, Elena; Costenbader, Karen H

2013-01-01

Objective Systemic lupus erythematosus (lupus) disproportionately affects women, racial/ethnic minorities and low-income populations. We held focus groups for women from medically underserved communities to discuss interventions to improve care. Methods From our Lupus Registry, we invited 282 women, > 18 years, residing in urban, medically underserved areas. Hospital-based clinics and support groups also recruited participants. Women were randomly assigned to 3 focus groups. 75-minute sessions were recorded, transcribed and coded thematically using interpretative phenomenologic analysis and single counting methods. We categorized interventions by benefits, limitations, target populations and implementation questions. Results 29 women with lupus participated in 3 focus groups, (n=9, 9, 11). 80% were African American and 83% were from medically underserved zip codes. Themes included the desire for lupus education, isolation at the time of diagnosis, emotional and physical barriers to care, and the need for assistance navigating the healthcare system. 20 of 29 participants (69%) favored a peer support intervention; 17 (59%) also supported a lupus health passport. Newly diagnosed women were optimal intervention targets. Improvements in quality of life and mental health were proposed outcome measures. Conclusion Women with lupus from medically underserved areas have unique needs best addressed with an intervention designed through collaboration between community members and researchers. PMID:23087258

Effects of a kinesthetic cursive handwriting intervention for grade 4-6 students.

PubMed

Roberts, Gwenyth I; Siever, Jodi E; Mair, Judith A

2010-01-01

We studied whether Grade 4-6 students who participated in a kinesthetic writing intervention improved in legibility, speed, and personal satisfaction with cursive handwriting. Small groups of students with handwriting difficulties were seen weekly for 7 wk using a kinesthetic writing system. A repeated measures design was used to evaluate change in global legibility, individual letter formation, specific features of handwriting, and personal satisfaction. Analysis revealed (1) a significant increase in ratings of global legibility (p <.01; clinically significant improvements in 39% of students); (2) significant improvements in letter formation and legibility features of baseline, closure, and line quality (all p < .05); (3) increased handwriting speed (p < .05; not clinically significant); and (4) significant increase in measures with personal satisfaction of handwriting (p < .01). CONCLUSION. A kinesthetic handwriting intervention may be effective in improving the skills of students with handwriting challenges.

Implementation of a School-wide Clinical Intervention Documentation System

PubMed Central

Stevenson, T. Lynn; Fox, Brent I.; Andrus, Miranda; Carroll, Dana

2011-01-01

Objective. To evaluate the effectiveness and impact of a customized Web-based software program implemented in 2006 for school-wide documentation of clinical interventions by pharmacy practice faculty members, pharmacy residents, and student pharmacists. Methods. The implementation process, directed by a committee of faculty members and school administrators, included preparation and refinement of the software, user training, development of forms and reports, and integration of the documentation process within the curriculum. Results. Use of the documentation tool consistently increased from May 2007 to December 2010. Over 187,000 interventions were documented with over $6.2 million in associated cost avoidance. Conclusions. Successful implementation of a school-wide documentation tool required considerable time from the oversight committee and a comprehensive training program for all users, with ongoing monitoring of data collection practices. Data collected proved to be useful to show the impact of faculty members, residents, and student pharmacists at affiliated training sites. PMID:21829264

Organizational Uses of Health Information Exchange to Change Cost and Utilization Outcomes: A Typology from a Multi-Site Qualitative Analysis.

PubMed

Vest, Joshua R; Abramson, Erika

2015-01-01

Health information exchange (HIE) systems facilitate access to patient information for a variety of health care organizations, end users, and clinical and organizational goals. While a complex intervention, organizations' usage of HIE is often conceptualized and measured narrowly. We sought to provide greater specificity to the concept of HIE as an intervention by formulating a typology of organizational HIE usage. We interviewed representatives of a regional health information organization and health care organizations actively using HIE information to change patient utilization and costs. The resultant typology includes three dimensions: user role, usage initiation, and patient set. This approach to categorizing how health care organizations are actually applying HIE information to clinical and business tasks provides greater clarity about HIE as an intervention and helps elucidate the conceptual linkage between HIE an organizational and patient outcomes.

Topical Review: Adherence Interventions for Youth on Gluten-Free Diets.

PubMed

Holbein, Christina E; Carmody, Julia K; Hommel, Kevin A

2018-05-01

To summarize gluten-free diet (GFD) nonadherence risk factors, nonadherence rates, and current intervention research within an integrative framework and to develop a research agenda for the development and implementation of evidence-based GFD adherence interventions. Topical review of literature published since 2008 investigating GFD adherence in pediatric samples. Reviews of pediatric studies indicate GFD nonadherence rates ranging from 19 to 56%. There are few evidence-based, published pediatric GFD adherence interventions. Novel assessments of GFD adherence are promising but require further study. Nonmodifiable and modifiable factors within individual, family, community, and health systems domains must be considered when developing future interventions. Clinical implications are discussed. Avenues for future research include development and refinement of adherence assessment tools and development of evidence-based GFD adherence interventions. Novel technologies (e.g., GFD mobile applications) require empirical study but present exciting opportunities for adherence intervention.

Relationships among NANDA-I diagnoses, nursing outcomes classification, and nursing interventions classification by nursing students for patients in medical-surgical units in Korea.

PubMed

Noh, Hyun Kyung; Lee, Eunjoo

2015-01-01

The purpose of this study was to identify NANDA-I, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC; NNN) linkages used by Korean nursing students during their clinical practice in medical-surgical units. A comparative descriptive research design was used to measure the effects of nursing interventions from 153 nursing students in South Korea. Nursing students selected NNN using a Web-based nursing process documentation system. Data were analyzed by paired t-test. Eighty-two NANDA-I diagnoses, 116 NOC outcomes, and 163 NIC interventions were identified. Statistically significant differences in patients' preintervention and postintervention outcome scores were observed. By determining patient outcomes linked to interventions and how the degree of outcomes change after interventions, the effectiveness of the interventions can be evaluated. © 2014 NANDA International, Inc.

Interventions to increase physician efficiency and comfort with an electronic health record system.

PubMed

Jalota, L; Aryal, M R; Mahmood, M; Wasser, T; Donato, A

2015-01-01

To determine comfort when using the Electronic Health Record (EHR) and increase in documentation efficiency after an educational intervention for physicians to improve their transition to a new EHR. This study was a single-center randomized, parallel, non-blinded controlled trial of real-time, focused educational interventions by physician peers in addition to usual training in the intervention arm compared with usual training in the control arm. Participants were 44 internal medicine physicians and residents stratified to groups using a survey of comfort with electronic media during rollout of a system-wide EHR and order entry system. Outcomes were median time to complete a progress note, notes completed after shift, and comfort with EHR at 20 and 40 shifts. In the intervention group, 73 education sessions averaging 14.4 (SD: 7.7) minutes were completed with intervention group participants, who received an average of 3.47 (SD: 2.1) interventions. Intervention group participants decreased their time to complete a progress note more quickly than controls over 30 shifts (p < 0.001) and recorded significantly fewer progress notes after scheduled duty hours (77 versus 292, p < 0.001). Comfort with EHRs increased significantly in both groups from baseline but did not differ significantly by group. Intervention group participants felt that the intervention was more helpful than their standard training (3.47 versus 1.95 on 4-point scale). Physicians teaching physicians during clinical work improved physician efficiency but not comfort with EHRs. More study is needed to determine best methods to assist those most challenged with new EHR rollouts.

Capturing the experiences of patients across multiple complex interventions: a meta-qualitative approach

PubMed Central

Webster, Fiona; Christian, Jennifer; Mansfield, Elizabeth; Bhattacharyya, Onil; Hawker, Gillian; Levinson, Wendy; Naglie, Gary; Pham, Thuy-Nga; Rose, Louise; Schull, Michael; Sinha, Samir; Stergiopoulos, Vicky; Upshur, Ross; Wilson, Lynn

2015-01-01

Objectives The perspectives, needs and preferences of individuals with complex health and social needs can be overlooked in the design of healthcare interventions. This study was designed to provide new insights on patient perspectives drawing from the qualitative evaluation of 5 complex healthcare interventions. Setting Patients and their caregivers were recruited from 5 interventions based in primary, hospital and community care in Ontario, Canada. Participants We included 62 interviews from 44 patients and 18 non-clinical caregivers. Intervention Our team analysed the transcripts from 5 distinct projects. This approach to qualitative meta-evaluation identifies common issues described by a diverse group of patients, therefore providing potential insights into systems issues. Outcome measures This study is a secondary analysis of qualitative data; therefore, no outcome measures were identified. Results We identified 5 broad themes that capture the patients’ experience and highlight issues that might not be adequately addressed in complex interventions. In our study, we found that: (1) the emergency department is the unavoidable point of care; (2) patients and caregivers are part of complex and variable family systems; (3) non-medical issues mediate patients’ experiences of health and healthcare delivery; (4) the unanticipated consequences of complex healthcare interventions are often the most valuable; and (5) patient experiences are shaped by the healthcare discourses on medically complex patients. Conclusions Our findings suggest that key assumptions about patients that inform intervention design need to be made explicit in order to build capacity to better understand and support patients with multiple chronic diseases. Across many health systems internationally, multiple models are being implemented simultaneously that may have shared features and target similar patients, and a qualitative meta-evaluation approach, thus offers an opportunity for cumulative learning at a system level in addition to informing intervention design and modification. PMID:26351182

Performance of magnetic field‐guided navigation system for interventional neurosurgical and cardiac procedures

PubMed Central

Chu, James C.H.; Hsi, Wen Chien; Hubbard, Lincoln; Zhang, Yunkai; Bernard, Damian; Reeder, Pamela; Lopes, Demetrius

2005-01-01

A hospital‐based magnetic guidance system (MGS) was installed to assist a physician in navigating catheters and guide wires during interventional cardiac and neurosurgical procedures. The objective of this study is to examine the performance of this magnetic field‐guided navigation system. Our results show that the system's radiological imaging components produce images with quality similar to that produced by other modern fluoroscopic devices. The system's magnetic navigation components also deflect the wire and catheter tips toward the intended direction. The physician, however, will have to oversteer the wire or catheter when defining the steering angle during the procedure. The MGS could be clinically useful in device navigation deflection and vessel access. PACS numbers: 07.55.Db, 07.85.‐m PMID:16143799

Carotid interventions and blood pressure.

PubMed

Hirschl, Mirko; Kundi, Michael

2014-12-01

Arterial baroreceptors are pressure sensors found in the carotid sinus near the bifurcation of the carotid artery and in the aortic arch. Carotid interventions, whether endovascular or surgical, affect this complicated control system and the post-interventional blood pressure behavior. Comparisons between the intervention techniques, however, are challenging due to the varying measurement methods, duration of observation, and patient populations. The question as to which interventional method is preferable, if undisturbed regulation of blood pressure is concerned, still remains unanswered. The fact that blood pressure events (i.e., hemodynamic instability, hypertension, unstable blood pressure) frequently occur both immediately after intervention and in the long term, mandates a particularly careful cardiopulmonary and blood pressure monitoring. Direct and indirect measurements of baroreceptor sensitivity can be helpful in identifying high-risk patients, although the association to hard clinical endpoints is rarely documented for methodological reasons.

Recovering activity and illusion: the nephrology day care unit.

PubMed

Remón Rodríguez, C; Quirós Ganga, P L; González-Outón, J; del Castillo Gámez, R; García Herrera, A L; Sánchez Márquez, M G

2011-01-01

Day Care Units are an alternative to hospital care that improves more efficiency. The Nephrology, by its technical characteristics, would be benefit greatly from further development of this care modality. The objectives of this study are to present the process we have developed the Nephrology Day Care Unit in the Puerto Real University Hospital (Cádiz, Spain). For this project we followed the Deming Management Method of Quality improvement, selecting opportunities, analyzing causes, select interventions, implement and monitor results. The intervention plan includes the following points: 1) Define the place of the Day Care Unit in the organization of our Clinical Department of Nephrology, 2) Define the Manual of organization, 3) Define the structural and equipment resources, 4) Define the Catalogue of services and procedures, 5) Standards of Care Processes. Protocols and Clinical Pathways; and 6) Information and Registration System. In the first 8 months we have been performed nearly 2000 procedures, which corresponds to an average of about 10 procedures per day, and essentially related to Hemodialysis in critical or acute patients, the Interventional Nephrology, the Clinical Nephrology and Peritoneal Dialysis. The development of the Nephrology Day Care Units can help to increase our autonomy, our presence in Hospitals, recover the progressive loss of clinical activity (diagnostic and therapeutic skills) in the past to the benefit of other Specialties. It also contributes to: Promote and develop the Diagnostic and Interventional Nephrology; improve the clinical management of patients with Primary Health Level, promote the Health Education and Investigation, collaborate in the Resources Management, and finally, to make more attractive and exciting our Specialty, both for nephrologists to training specialists.

Family intervention to control type 2 diabetes: a controlled clinical trial.

PubMed

García-Huidobro, Diego; Bittner, Marcela; Brahm, Paulina; Puschel, Klaus

2011-02-01

Chilean patients with type 2 diabetes mellitus (T2DM) have a low rate of blood sugar control. We studied the effectiveness of a culturally sensitive family oriented intervention designed to improve metabolic control in primary care patients with uncontrolled T2DM. Patients with T2DM from three primary care clinics in Santiago, Chile were randomly selected for inclusion if they had a recent HbA1c ≥7%, were between 18 and 70 years old and lived with a family member. Patients from one clinic received the family oriented intervention; patients from the other two (control) clinics received standard care. The intervention involved family members in care and included family counselling during clinic visits, family meetings and home visits. The primary outcome was HbA1c, measured at 6 and 12 months. A total of 243 patients were enrolled and 209 (86%) completed the study. The intervention was fully administered to only 34% of patients in the intervention clinic. The reduction in the HbA1c from baseline to 12 months was not significantly different between clinics. During the second 6-month period, when the intervention was more intensive, the patients in the intervention clinic significantly improved their HbA1c (P < 0.001) compared to the control patients. A family intervention for the control of T2DM was associated with a significant reduction in HbA1c when the intervention was provided. Incomplete implementation, low statistical power and potential confounding variables between groups could be some of the main factors that explain the lack of difference between clinics in the 12-month period.

Bariatric Embolization of the Gastric Arteries for the Treatment of Obesity

PubMed Central

Weiss, Clifford R.; Gunn, Andrew J.; Kim, Charles Y.; Paxton, Ben E.; Kraitchman, Dara L.; Arepally, Aravind

2015-01-01

Obesity is a public health epidemic in the United States, which results in significant morbidity, mortality, and cost to the healthcare system. Despite advancements in therapeutic options for the bariatric patients, the number of overweight and obese individuals continues to rise. Thus, complimentary or alternative treatments to lifestyle changes and surgery are urgently needed. Embolization of the left gastric artery, or ‘bariatric arterial embolization’, has been shown to modulate body weight in animal models and early clinical studies. If successful, bariatric arterial embolization represents a potential minimally invasive approach to treat obesity offered by interventional radiologists. The purpose of the following review will be to introduce the interventional radiologist to bariatric arterial embolization by presenting its physiologic and anatomic bases, reviewing the pre-clinical and clinical data, and discussing current and future investigations. PMID:25777177

Application of neuroscience to technology in stroke rehabilitation.

PubMed

Burns, Martha S

2008-01-01

The past decade has seen remarkable advances in our understanding of mechanisms that drive functional neuroplastic change after brain injury and the mirror neuron system that appears essential for language learning and communicative interaction. This article describes five neuroscience-based interventions available for clinical practice, with a discussion of the potential value of mirror neurons in stroke rehabilitation. Case-study data on three adults with aphasia who received various combinations of neuroscience-derived technological interventions are provided to inform the clinician of the potential advantages of technology as an adjunct to, not a substitution for, conventional therapeutic intervention.

Prospective Pilot Study of the Mastering Each New Direction Psychosocial Family Systems Program for Pediatric Chronic Illness.

PubMed

Distelberg, Brian; Tapanes, Daniel; Emerson, Natacha D; Brown, Whitney N; Vaswani, Deepti; Williams-Reade, Jackie; Anspikian, Ara M; Montgomery, Susanne

2018-03-01

Psychosocial interventions for pediatric chronic illness (CI) have been shown to support health management. Interventions that include a family systems approach offer potentially stronger and more sustainable improvements. This study explores the biopsychosocial benefits of a novel family systems psychosocial intervention (MEND: Mastering Each New Direction). Forty-five families participated in a 21-session intensive outpatient family systems-based program for pediatric CI. Within this single arm design, families were measured on five domains of Health-Related Quality of Life (HRQL) self-report measures; Stress, Cognitive Functioning, Mental Health, Child HRQL, Family Functioning. Both survey and biological measures (stress: catecholamine) were used in the study. Results from multivariate general linear models showed positive pre-, post-, and 3-month posteffects in all five domains. The program effects ranged from small to moderate (η 2  = .07-.64). The largest program effects were seen in the domains of cognitive functioning (η 2  = .64) and stress (η 2  = .27). Also, between disease groups, differences are noted and future implications for research and clinical practice are discussed. Conclusions suggest that the MEND program may be useful in helping families manage pediatric chronic illnesses. Study results also add to the growing body of literature suggesting that psychosocial interventions for pediatric chronic illness benefit from a family systems level of intervention. © 2017 Family Process Institute.

Does recruitment source moderate treatment effectiveness? A subgroup analysis from the EVIDENT study, a randomised controlled trial of an internet intervention for depressive symptoms

PubMed Central

Gamon, Carla; Späth, Christina; Berger, Thomas; Meyer, Björn; Hohagen, Fritz; Hautzinger, Martin; Lutz, Wolfgang; Vettorazzi, Eik; Moritz, Steffen; Schröder, Johanna

2017-01-01

Objective This study aims to examine whether the effects of internet interventions for depression generalise to participants recruited in clinical settings. Design This study uses subgroup analysis of the results of a randomised, controlled, single-blind trial. Setting The study takes place in five diagnostic centres in Germany. Participants A total of 1013 people with mild to moderate depressive symptoms were recruited from clinical sources as well as internet forums, statutory insurance companies and other sources. Interventions This study uses either care-as-usual alone (control) or a 12-week internet intervention (Deprexis) plus usual care (intervention). Main outcome measures The primary outcome measure was self-rated depression severity (Patient Health Questionnaire-9) at 3 months and 6 months. Further measures ranged from demographic and clinical parameters to a measure of attitudes towards internet interventions (Attitudes towards Psychological Online Interventions Questionnaire). Results The recruitment source was only associated with very few of the examined demographic and clinical characteristics. Compared with participants recruited from clinical sources, participants recruited through insurance companies were more likely to be employed. Clinically recruited participants were as severely affected as those from other recruitment sources but more sceptical of internet interventions. The effectiveness of the intervention was not differentially associated with recruitment source (treatment by recruitment source interaction=0.28, p=0.84). Conclusion Our results support the hypothesis that the intervention we studied is effective across different recruitment sources including clinical settings. Trial registration number ClinicalTrials.gov NCT01636752. PMID:28710212

A qualitative study of implementation and adaptations to Progressive Tinnitus Management (PTM) delivery.

PubMed

Tuepker, Anaïs; Elnitsky, Christine; Newell, Summer; Zaugg, Tara; Henry, James A

2018-01-01

Tinnitus is a common condition, especially prevalent among military Veterans. Progressive Tinnitus Management (PTM) is an interdisciplinary, structured, stepped-care approach to providing clinical services, including teaching coping skills, to people bothered by tinnitus. PTM has been shown to be effective at reducing functional distress, but implementation of the intervention outside of a research setting has not been studied, even though dissemination is underway within the Veterans Health Administration (VHA) system in the United States. This study was designed to address a gap in knowledge of PTM clinical implementation to date, with a focus on factors facilitating or hindering implementation in VHA audiology and mental health clinic contexts, and whether implementing sites had developed intervention adaptations. Qualitative interviews were conducted with 21 audiology and mental health clinicians and service chiefs across a regional service network. Interviews were transcribed and coded using a hybrid inductive-deductive analytic approach guided by existing implementation research frameworks and then iteratively developed for emergent themes. PTM prioritization was rare overall, with providers across disciplines challenged by lack of capacity for implementation, but with differences by discipline in challenges to prioritization. Where PTM was prioritized and delivered, this was facilitated by perception of unique value, provider's own experience of tinnitus, observation/experience with PTM delivery, intervention fit with provider's skills, and an environment with supportive leadership and adaptive reserve. PTM was frequently adapted to local contexts to address delivery challenges and diversify patient options. Adaptations included shifting from group to individual formats, reducing or combining sessions, and employing novel therapeutic approaches. Existing adaptations highlight the need to better understand mechanisms underlying PTM's effectiveness, and research on the impact of adaptations on patient outcomes is an important next step. Prioritization of PTM is a key barrier to the scale up and spread of this evidence-based intervention. Developing clinician champions may facilitate dissemination, especially if accompanied by signals of systemic prioritization. Novel approaches exposing clinicians and administrators to PTM may identify and develop clinical champions. Acknowledging the potential for PTM adaptations may make delivery more feasible in the context of existing system constraints and priorities.

Determining if an older adult can make and execute decisions to live safely at home: a capacity assessment and intervention model

PubMed Central

Skelton, Felicia; Kunik, Mark E.; Regev, Tziona; Naik, Aanand D.

2009-01-01

Determining an older adult’s capacity to live safely and independently in the community presents a serious and complicated challenge to the health care system. Evaluating one’s ability to make and execute decisions regarding safe and independent living incorporates clinical assessments, bioethical considerations, and often legal declarations of capacity. Capacity assessments usually result in life changes for patients and their families, including a caregiver managing some everyday tasks, placement outside of the home, and even legal guardianship. The process of determining capacity and recommending intervention is often inefficient and highly variable in most cases. Physicians are rarely trained to conduct capacity assessments and assessment methods are heterogeneous. An interdisciplinary team of clinicians developed the capacity assessment and intervention (CAI) model at a community outpatient geriatrics clinic to address these critical gaps. This report follows one patient through the entire CAI model, describing processes for a typical case. It then examines two additional case reports that highlight common challenges in capacity assessment. The CAI model uses assessment methods common to geriatrics clinical practice and conducts assessments and interventions in a standardized fashion. Reliance on common, validated measures increases generalizability of the model across geriatrics practice settings and patient populations. PMID:19481271

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

PubMed Central

Park, Hyeoun-Ae; Jeon, Eunjoo; Chung, Eunja

2012-01-01

Objectives The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. Methods This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. Results We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. Conclusions The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system. PMID:22844649

Real-time self-calibration of a tracked augmented reality display

NASA Astrophysics Data System (ADS)

Baum, Zachary; Lasso, Andras; Ungi, Tamas; Fichtinger, Gabor

2016-03-01

PURPOSE: Augmented reality systems have been proposed for image-guided needle interventions but they have not become widely used in clinical practice due to restrictions such as limited portability, low display refresh rates, and tedious calibration procedures. We propose a handheld tablet-based self-calibrating image overlay system. METHODS: A modular handheld augmented reality viewbox was constructed from a tablet computer and a semi-transparent mirror. A consistent and precise self-calibration method, without the use of any temporary markers, was designed to achieve an accurate calibration of the system. Markers attached to the viewbox and patient are simultaneously tracked using an optical pose tracker to report the position of the patient with respect to a displayed image plane that is visualized in real-time. The software was built using the open-source 3D Slicer application platform's SlicerIGT extension and the PLUS toolkit. RESULTS: The accuracy of the image overlay with image-guided needle interventions yielded a mean absolute position error of 0.99 mm (95th percentile 1.93 mm) in-plane of the overlay and a mean absolute position error of 0.61 mm (95th percentile 1.19 mm) out-of-plane. This accuracy is clinically acceptable for tool guidance during various procedures, such as musculoskeletal injections. CONCLUSION: A self-calibration method was developed and evaluated for a tracked augmented reality display. The results show potential for the use of handheld image overlays in clinical studies with image-guided needle interventions.

A System-Level Approach to Overweight and Obesity in the Veterans Health Administration.

PubMed

Raffa, Susan D; Maciejewski, Matthew L; Zimmerman, Lindsey E; Damschroder, Laura J; Estabrooks, Paul A; Ackermann, Ronald T; Tsai, Adam G; Histon, Trina; Goldstein, Michael G

2017-04-01

Healthcare systems are challenged by steady increases in the number of patients who are overweight and obese. Large-scale, evidence-based behavioral approaches for addressing overweight and obesity have been successfully implemented in systems such as the Veterans Health Administration (VHA). These population-based interventions target reduction in risk for obesity-associated conditions through lifestyle change and weight loss, and are associated with modest weight loss. Despite the fact that VHA has increased the overall reach of these behavioral interventions, the number of high-risk overweight and obese patients continues to rise. Recommendations for weight loss medications and bariatric surgery are included in clinical practice guidelines for the management of overweight and obesity, but these interventions are underutilized. During a recent state of the art conference on weight management held by VHA, subject matter experts identified challenges and gaps, as well as potential solutions and overarching policy recommendations, for implementing an integrated system-wide approach for improving population-based weight management.

Digital Interventions for Problematic Cannabis Users in Non-Clinical Settings: Findings from a Systematic Review and Meta-Analysis.

PubMed

Hoch, Eva; Preuss, Ulrich W; Ferri, Marica; Simon, Roland

2016-01-01

Existing cannabis treatment programs reach only a very limited proportion of people with cannabis-related problems. The aim of this systematic review and meta-analysis was to assess the effectiveness of digital interventions applied outside the health care system in reducing problematic cannabis use. We systematically searched the Cochrane Central Register of Controlled Trials (2015), PubMed (2009-2015), Medline (2009-2015), Google Scholar (2015) and article reference lists for potentially eligible studies. Randomized controlled trials examining the effects of internet- or computer-based interventions were assessed. Study effects were estimated by calculating effect sizes (ESs) using Cohen's d and Hedges' g bias-corrected ES. The primary outcome assessed was self-reported cannabis use, measured by a questionnaire. Fifty-two studies were identified. Four studies (including 1,928 participants) met inclusion criteria. They combined brief motivational interventions and cognitive behavioral therapy delivered online. All studies were of good quality. The pooled mean difference (x0394; = 4.07) and overall ES (0.11) give evidence of small effects at 3-month follow-up in favor of digital interventions. Digital interventions can help to successfully reduce problematic cannabis use outside clinical settings. They have some potential to overcome treatment barriers and increase accessibility for at-risk cannabis users. © 2016 S. Karger AG, Basel.

How can research keep up with eHealth? Ten strategies for increasing the timeliness and usefulness of eHealth research.

PubMed

Baker, Timothy B; Gustafson, David H; Shah, Dhavan

2014-02-19

eHealth interventions appear and change so quickly that they challenge the way we conduct research. By the time a randomized trial of a new intervention is published, technological improvements and clinical discoveries may make the intervention dated and unappealing. This and the spate of health-related apps and websites may lead consumers, patients, and caregivers to use interventions that lack evidence of efficacy. This paper aims to offer strategies for increasing the speed and usefulness of eHealth research. The paper describes two types of strategies based on the authors' own research and the research literature: those that improve the efficiency of eHealth research, and those that improve its quality. Efficiency strategies include: (1) think small: conduct small studies that can target discrete but significant questions and thereby speed knowledge acquisition; (2) use efficient designs: use such methods as fractional-factorial and quasi-experimental designs and surrogate endpoints, and experimentally modify and evaluate interventions and delivery systems already in use; (3) study universals: focus on timeless behavioral, psychological, and cognitive principles and systems; (4) anticipate the next big thing: listen to voices outside normal practice and connect different perspectives for new insights; (5) improve information delivery systems: researchers should apply their communications expertise to enhance inter-researcher communication, which could synergistically accelerate progress and capitalize upon the availability of "big data"; and (6) develop models, including mediators and moderators: valid models are remarkably generative, and tests of moderation and mediation should elucidate boundary conditions of effects and treatment mechanisms. Quality strategies include: (1) continuous quality improvement: researchers need to borrow engineering practices such as the continuous enhancement of interventions to incorporate clinical and technological progress; (2) help consumers identify quality: consumers, clinicians, and others all need to easily identify quality, suggesting the need to efficiently and publicly index intervention quality; (3) reduce the costs of care: concern with health care costs can drive intervention adoption and use and lead to novel intervention effects (eg, reduced falls in the elderly); and (4) deeply understand users: a rigorous evaluation of the consumer's needs is a key starting point for intervention development. The challenges of distinguishing and distributing scientifically validated interventions are formidable. The strategies described are meant to spur discussion and further thinking, which are important, given the potential of eHealth interventions to help patients and families.

How Can Research Keep Up With eHealth? Ten Strategies for Increasing the Timeliness and Usefulness of eHealth Research

PubMed Central

2014-01-01

Background eHealth interventions appear and change so quickly that they challenge the way we conduct research. By the time a randomized trial of a new intervention is published, technological improvements and clinical discoveries may make the intervention dated and unappealing. This and the spate of health-related apps and websites may lead consumers, patients, and caregivers to use interventions that lack evidence of efficacy. Objective This paper aims to offer strategies for increasing the speed and usefulness of eHealth research. Methods The paper describes two types of strategies based on the authors’ own research and the research literature: those that improve the efficiency of eHealth research, and those that improve its quality. Results Efficiency strategies include: (1) think small: conduct small studies that can target discrete but significant questions and thereby speed knowledge acquisition; (2) use efficient designs: use such methods as fractional-factorial and quasi-experimental designs and surrogate endpoints, and experimentally modify and evaluate interventions and delivery systems already in use; (3) study universals: focus on timeless behavioral, psychological, and cognitive principles and systems; (4) anticipate the next big thing: listen to voices outside normal practice and connect different perspectives for new insights; (5) improve information delivery systems: researchers should apply their communications expertise to enhance inter-researcher communication, which could synergistically accelerate progress and capitalize upon the availability of “big data”; and (6) develop models, including mediators and moderators: valid models are remarkably generative, and tests of moderation and mediation should elucidate boundary conditions of effects and treatment mechanisms. Quality strategies include: (1) continuous quality improvement: researchers need to borrow engineering practices such as the continuous enhancement of interventions to incorporate clinical and technological progress; (2) help consumers identify quality: consumers, clinicians, and others all need to easily identify quality, suggesting the need to efficiently and publicly index intervention quality; (3) reduce the costs of care: concern with health care costs can drive intervention adoption and use and lead to novel intervention effects (eg, reduced falls in the elderly); and (4) deeply understand users: a rigorous evaluation of the consumer’s needs is a key starting point for intervention development. Conclusions The challenges of distinguishing and distributing scientifically validated interventions are formidable. The strategies described are meant to spur discussion and further thinking, which are important, given the potential of eHealth interventions to help patients and families. PMID:24554442

Automated real-time data acquisition and analysis of cardiorespiratory function.

PubMed

Moorman, R C; Mackenzie, C F; Ho, G H; Barnas, G M; Wilson, P D; Matjasko, M J

1991-01-01

Microcomputer generation of an automated record without complexity or operator intervention is desirable in many circumstances. We developed a microcomputer system specifically designed for simplified automated collection of cardiorespiratory data in research and clinical environments. We tested the system during possible extreme clinical conditions by comparison with a patient simulator. Ranges used were heart rate of 35-182 beats per minute, systemic blood pressures of 65-147 mmHg and venous blood pressures of 14-37 mmHg, all with superimposed respiratory variation of 0-24 mmHg. We also tested multiple electrocardiographic dysrhythmias. The results showed that there were no clinically relevant differences in vascular pressures, heart rate, and other variables between computer processed and simulator values. Manually and computer recorded physiological variables were compared to simulator values and the results show that computer values were more accurate. The system was used routinely in 21 animal research experiments over a 4 month period employing a total of 270 collection periods. The file system integrity was tested and found to be satisfactory, even during power failures. Unlike other data collection systems this one (1) requires little or no operator intervention and training, (2) has been rigorously tested for accuracy using a wide variety of extreme patient conditions, (3) has had computer derived values measured against a standardized reference, (4) is reliable against external sources of computer failure, and (5) has screen and printout presentations with quick and easily understandable formats.

A telephone-delivered multiple health behaviour change intervention for colorectal cancer survivors: making the case for cost-effective healthcare.

PubMed

Gordon, L G; Patrao, T; Kularatna, S; Hawkes, A L

2015-11-01

In patients with colorectal cancer, a trial of a telephone-delivered multiple health behaviour change intervention, using acceptance commitment therapy strategies, found benefits for health and psychosocial outcomes including increased physical activity, improved dietary habits and lower body mass index. Our aim was to address the health economic outcomes by assessing the health system cost and health utility impacts of the intervention. A cost-consequences analysis was performed using data from a two-group randomised controlled intervention trial (n = 410). Outcomes included health-related quality of life (HRQoL), health utility and health system costs. At 12 months, clinically meaningful improvements were found for SF-6D over time but no significant differences were found between groups (P = 0.95). The cost of delivering the 6-month intervention was on average €280 per person and made up 21% of overall healthcare costs for participants during the intervention period. Excluding intervention costs, costs were similar for health professional visits and medications across groups. Despite significant positive intervention effects on health behaviours, health utility and HRQoL scores were similar across groups. On the basis that intervention costs were small and physical activity, diet and weight management improved, on balance the intervention is potentially a worthwhile investment in healthcare funds. ACTRN12608000399392. © 2015 John Wiley & Sons Ltd.

Evaluation Of A Maternal Health Program In Uganda And Zambia Finds Mixed Results On Quality Of Care And Satisfaction.

PubMed

Kruk, Margaret E; Vail, Daniel; Austin-Evelyn, Katherine; Atuyambe, Lynn; Greeson, Dana; Grépin, Karen Ann; Kibira, Simon P S; Macwan'gi, Mubiana; Masvawure, Tsitsi B; Rabkin, Miriam; Sacks, Emma; Simbaya, Joseph; Galea, Sandro

2016-03-01

Saving Mothers, Giving Life is a multidonor program designed to reduce maternal mortality in Uganda and Zambia. We used a quasi-random research design to evaluate its effects on provider obstetric knowledge, clinical confidence, and job satisfaction, and on patients' receipt of services, perceived quality, and satisfaction. Study participants were 1,267 health workers and 2,488 female patients. Providers' knowledge was significantly higher in Ugandan and Zambian intervention districts than in comparison districts, and in Uganda there were similar positive differences for providers' clinical confidence and job satisfaction. Patients in Ugandan intervention facilities were more likely to give high ratings for equipment availability, providers' knowledge and communication skills, and care quality, among other factors, than patients in comparison facilities. There were fewer differences between Zambian intervention and comparison facilities. Country differences likely reflect differing intensity of program implementation and the more favorable geography of intervention districts in Uganda than in Zambia. National investments in the health system and provider training and the identification of intervention components most associated with improved performance will be required for scaling up and sustaining the program. Project HOPE—The People-to-People Health Foundation, Inc.

Clinical review: Riedel's thyroiditis: a clinical review.

PubMed

Hennessey, James V

2011-10-01

Riedel's thyroiditis is a rare inflammatory process involving the thyroid and surrounding cervical tissues and is associated with various forms of systemic fibrosis. Riedel's presentation is complex, including a thyroid mass associated with local symptoms, characteristic biochemical abnormalities such as hypocalcemia and hypothyroidism, as well as the involvement of a wide range of other organ systems. Diagnosis of Riedel's thyroiditis requires histopathological confirmation, but due to high complication rates, the role of surgical intervention is limited to airway decompression and diagnostic tissue retrieval. Unique among processes of the thyroid, Riedel's is commonly treated with long-term antiinflammatory medications to arrest progression and maintain a symptom-free course. Due to its rarity, Riedel's may not be immediately diagnosed, so clinicians benefit from recognizing the constellation of findings that should make prompt diagnosis possible. A review of print and electronic reviews was conducted. Source references were identified, and available literature was reviewed. A search of the PubMed database using the search term "Riedel's thyroiditis" was cross-referenced with associated clinical findings, systemic fibrosis diagnoses, and therapeutic search terms. Because most of the literature consisted of case reports and very small series, inclusion of identified articles was based on clinical descriptions of the subjects included and the criteria for diagnosis reported. More weight was attributed to series, using contemporary criteria for diagnosis. Case reports were included if the diagnosis was clear and clinical presentation was unique to illustrate the spectrum of disease. Because the majority of therapeutic intervention data were based upon case reports and very small series, an evidence-based approach was problematic, but information is presented as objectively and with as much balance as the limited quality of the data allows. Clinical awareness of the characteristic presentations of Riedel's thyroiditis should enhance our ability to make this diagnosis in a timely and focused manner. Recognition of certain clinical finding patterns will increase the likelihood of recognizing Riedel's thyroiditis promptly. Local restrictive or infiltrative symptoms out of proportion to a demonstrable mass or simultaneous biochemical deficiencies especially of calcium should lead the clinician to consider this diagnosis. Likewise in this setting, the surgeon alert to this possibility may minimize overly aggressive surgical intervention, thus avoiding complications. Once Riedel's thyroiditis is diagnosed, the application of antiinflammatory therapies may greatly enhance the clinical outcome. Understanding the pathophysiological relationship of this entity with other forms of systemic fibrosis and the role that IgG4 may play in this process should result in enhanced diagnostic and therapeutic tools in the future.

A personal health information toolkit for health intervention research.

PubMed

Kizakevich, Paul N; Eckhoff, Randall; Weger, Stacey; Weeks, Adam; Brown, Janice; Bryant, Stephanie; Bakalov, Vesselina; Zhang, Yuying; Lyden, Jennifer; Spira, James

2014-01-01

With the emergence of mobile health (mHealth) apps, there is a growing demand for better tools for developing and evaluating mobile health interventions. Recently we developed the Personal Health Intervention Toolkit (PHIT), a software framework which eases app implementation and facilitates scientific evaluation. PHIT integrates self-report and physiological sensor instruments, evidence-based advisor logic, and self-help interventions such as meditation, health education, and cognitive behavior change. PHIT can be used to facilitate research, interventions for chronic diseases, risky behaviors, sleep, medication adherence, environmental monitoring, momentary data collection health screening, and clinical decision support. In a series of usability evaluations, participants reported an overall usability score of 4.5 on a 1-5 Likert scale and an 85 score on the System Usability Scale, indicating a high percentile rank of 95%.

The impact of the Advancing Social-communication And Play (ASAP) intervention on preschoolers with autism spectrum disorder.

PubMed

Dykstra, Jessica R; Boyd, Brian A; Watson, Linda R; Crais, Elizabeth R; Baranek, Grace T

2012-01-01

This study evaluates an intervention targeting social-communication and play skills (Advancing Social-communication And Play; ASAP) implemented by school staff in a public preschool setting. With increases in enrollment of children with autism spectrum disorder (ASD) in school systems, establishing the effectiveness and feasibility of interventions implemented in school settings is important. In clinical settings, interventions targeting social-communication and play behaviors have increased these skills and impacted later language abilities. Results of this single-case design study indicated the ASAP intervention had a positive impact on social-communication and play skills for three preschoolers with ASD. All participants showed either increases in frequency or more stability in targeted behaviors. Social validity results provide additional support for the use of ASAP with preschoolers with ASD.

Increasing access to specialty care: patient discharges from a gastroenterology clinic.

PubMed

Tuot, Delphine S; Sewell, Justin L; Day, Lukejohn; Leeds, Kiren; Chen, Alice Hm

2014-10-01

Access to specialty care among safety net patients in the United States is inadequate. Discharging appropriate patients to routine primary care follow-up may improve specialty care access. We sought to identify, by consensus, patients who could safely be discharged from a gastroenterology (GI) clinic, and to evaluate the impact of the discharges on GI clinic work flow. Pre- and post intervention. We developed and implemented a modified Delphi process. Gastroenterologists and primary care providers (PCPs) rated their comfort (using 5-point Likert scales) with discharging patients immediately post endoscopy for 24 clinical scenarios, assuming formal recommendations were communicated to the PCP. We examined the impact of implementing these criteria on clinic wait times and on the ratio of new to follow-up visits. All gastroenterologists (100%; 7 of 7) and 71.0% of PCPs (130 of 183) participated. Consensus was achieved for 13 of the 24 clinical scenarios for which discharge criteria were developed. Post intervention, 403 patients were discharged from the GI clinic, compared with 0 patients in the same 4 calendar months pre-intervention. The ratio of new to follow-up appointments increased from 0.9:1 to 1:1 (P = .05). Median wait time for the third next available appointment at GI clinics decreased from 158 days to 74 days (P = .0001). Discharging patients from specialty care back to primary care with consensus standards is one method to improve access to specialty care. Understanding the concerns of all stakeholders is necessary to refine and disseminate this process to other specialties and healthcare systems to ensure timely access to specialty services for all patients.

The use of electronic medical records for recruitment in clinical trials: findings from the Lifestyle Intervention for Treatment of Diabetes trial.

PubMed

Effoe, Valery S; Katula, Jeffrey A; Kirk, Julienne K; Pedley, Carolyn F; Bollhalter, Linda Y; Brown, W Mark; Savoca, Margaret R; Jones, Stedman T; Baek, Janet; Bertoni, Alain G

2016-10-13

The use of the electronic medical record (EMR) system in recruitment in clinical trials has the potential for providing a very reliable and cost-effective recruiting methodology which may improve participant recruitment in clinical trials. We examined a recruitment approach centered on the use of the EMR, as well as other traditional methods, in the Lifestyle Intervention for Treatment of Diabetes (LIFT Diabetes) trial. LIFT Diabetes is a randomized controlled trial designed to investigate the effects of two contrasting interventions on cardiovascular disease risk: a community-based intensive lifestyle program aimed at achieving weight loss and a clinic-based enhanced diabetes self-management program. Eligible participants were overweight/obese (body mass index, BMI ≥25 kg/m 2 ) patients with type 2 diabetes who were aged 21 years or older. Recruitment strategies included the use of the EMR system (primary), direct referrals, media advertisements, and community screenings. A total of 1102 telephone screens were conducted, resulting in randomization of 260 participants (61.5 % from EMR, mean age 56.3 years, 66.2 % women, 48.1 % non-Hispanic blacks) over a 21-month period, with a yield of 23.6 %. Recruitment yields differed by recruitment method, with referrals having the highest yield (27.5 %). A history of cardiovascular disease was the main health reason for exclusion from the study (16.5 %). An additional 8.9 % were excluded for BMI <25 kg/m 2 (<27 kg/m 2 for insulin users), 5.4 % could not exercise, 5.2 % had an HbA1c >11 %, and 34.9 % were excluded for other non-medical reasons. Exclusion criteria did not appear to differentially affect enrollment in terms of race or ethnicity. Future clinical studies should tailor their recruitment strategies based on the participant demographics of interest. Efficient methods such as using the EMR system and referrals should be prioritized over labor-intensive, low-yielding methods such as community screenings and mass mailings. ClinicalTrials.gov: NCT01806727 . Registered on 5 March 2013.

S4HARA: System for HIV/AIDS resource allocation.

PubMed

Lasry, Arielle; Carter, Michael W; Zaric, Gregory S

2008-03-26

HIV/AIDS resource allocation decisions are influenced by political, social, ethical and other factors that are difficult to quantify. Consequently, quantitative models of HIV/AIDS resource allocation have had limited impact on actual spending decisions. We propose a decision-support System for HIV/AIDS Resource Allocation (S4HARA) that takes into consideration both principles of efficient resource allocation and the role of non-quantifiable influences on the decision-making process for resource allocation. S4HARA is a four-step spreadsheet-based model. The first step serves to identify the factors currently influencing HIV/AIDS allocation decisions. The second step consists of prioritizing HIV/AIDS interventions. The third step involves allocating the budget to the HIV/AIDS interventions using a rational approach. Decision-makers can select from several rational models of resource allocation depending on availability of data and level of complexity. The last step combines the results of the first and third steps to highlight the influencing factors that act as barriers or facilitators to the results suggested by the rational resource allocation approach. Actionable recommendations are then made to improve the allocation. We illustrate S4HARA in the context of a primary healthcare clinic in South Africa. The clinic offers six types of HIV/AIDS interventions and spends US$750,000 annually on these programs. Current allocation decisions are influenced by donors, NGOs and the government as well as by ethical and religious factors. Without additional funding, an optimal allocation of the total budget suggests that the portion allotted to condom distribution be increased from 1% to 15% and the portion allotted to prevention and treatment of opportunistic infections be increased from 43% to 71%, while allocation to other interventions should decrease. Condom uptake at the clinic should be increased by changing the condom distribution policy from a pull system to a push system. NGOs and donors promoting antiretroviral programs at the clinic should be sensitized to the results of the model and urged to invest in wellness programs aimed at the prevention and treatment of opportunistic infections. S4HARA differentiates itself from other decision support tools by providing rational HIV/AIDS resource allocation capabilities as well as consideration of the realities facing authorities in their decision-making process.

Impact of telemonitoring approaches on integrated HIV and TB diagnosis and treatment interventions in sub-Saharan Africa: a scoping review.

PubMed

Yah, Clarence S; Tambo, Ernest; Khayeka-Wandabwa, Christopher; Ngogang, Jeanne Y

2017-01-01

Background: This paper explores telemonitoring/mhealth approaches as a promising real time and contextual strategy in overhauling HIV and TB interventions quality access and uptake, retention,adherence and coverage impact in endemic and prone-epidemic prevention and control in sub-Sahara Africa. Methods: The scoping review method was applied in acknowledged journals indexing platforms including Medline, Embase, Global Health, PubMed, MeSH PsycInfo, Scopus and Google Scholar to identify relevant articles pertaining to telemonitoring as a proxy surrogate method in reinforcing sustainability of HIV/TB prevention/treatment interventions in sub-Saharan Africa. Full papers were assessed and those selected that fosters evidence on telemonitoring/mhealth diagnosis, treatment approaches and strategies in HIV and TB prevention and control were synthesized and analyzed. Results: We found telemonitoring/mhealth approach as a more efficient and sustained proxy in HIV and TB risk reduction strategies for early diagnosis and prompt quality clinical outcomes. It can significantly contribute to decreasing health systems/patients cost, long waiting time in clinics, hospital visits, travels and time off/on from work. Improved integrated HIV and TB telemonitoring systems sustainability hold great promise in health systems strengthening including patient centered early diagnosis and care delivery systems, uptake and retention to medications/services and improving patients' survival and quality of life. Conclusion: Telemonitoring/mhealth (electronic phone text/video/materials messaging)acceptability, access and uptake are crucial in monitoring and improving uptake, retention,adherence and coverage in both local and national integrated HIV and TB programs and interventions. Moreover, telemonitoring is crucial in patient-providers-health professional partnership, real-time quality care and service delivery, antiretroviral and anti-tuberculous drugs improvement, susceptibility monitoring and prescription choice, reinforcing cost effective HIV and TB integrated therapy model and survival rate.

Outcomes associated with virtual reality in psychological interventions: where are we now?

PubMed

Turner, Wesley A; Casey, Leanne M

2014-12-01

The impending commercial release of affordable VR systems is likely to accelerate both the opportunity and demand for VR applications that specifically target psychological conditions. The aim of this study was to conduct a meta-analysis of outcomes associated with VR psychological interventions and to examine the methodological rigour used in these interventions. Literature search was conducted via Ovid, ProQuest Psychology Journals and ScienceDirect (Psychology) databases. Interventions were required to: be published between 1980 to 2014; use a randomised controlled trial design; be published in a scholarly journal; focused primarily on psychological/behavioural intervention; include validated measures; include reported means and standard deviations of outcome measures; and include one group with clinical/subclinical disorders, syndromes or distressing behaviours. Thirty eligible studies were identified. Random effects meta-analysis found an overall moderate effect size for VR interventions. Individual meta-analyses found an overall large effect size against non-intervention wait-lists and an overall moderate effect size against active interventions. No correlation was found between treatment outcomes and methodological rigour. Limitations may include limited study numbers, the use of a single coder, a need for more in-depth analyses of variation in form VR intervention, and omission of presence as a moderating factor. The current review supports VR interventions as efficacious, promising forms of psychological treatment. Use of reporting guidelines such as the CONSORT and CONSORT-EHEALTH statements should promote greater emphasis on methodological rigour, providing a firm foundation for the further development of clinical VR applications. Copyright © 2014 Elsevier Ltd. All rights reserved.

Patient-centered interventions to improve medication management and adherence: a qualitative review of research findings

PubMed Central

Kuntz, Jennifer L.; Safford, Monika M.; Singh, Jasvinder A.; Phansalkar, Shobha; Slight, Sarah P.; Her, Qoua Liang; Lapointe, Nancy Allen; Mathews, Robin; O’Brien, Emily; Brinkman, William B.; Hommel, Kevin; Farmer, Kevin C.; Klinger, Elissa; Maniam, Nivethietha; Sobko, Heather J.; Bailey, Stacy C.; Cho, Insook; Rumptz, Maureen H.; Vandermeer, Meredith L.; Hornbrook, Mark C.

2018-01-01

Objective Patient-centered approaches to improving medication adherence hold promise, but evidence of their effectiveness is unclear. This review reports the current state of scientific research around interventions to improve medication management through four patient-centered domains: shared decision-making, methods to enhance effective prescribing, systems for eliciting and acting on patient feedback about medication use and treatment goals, and medication-taking behavior. Methods We reviewed literature on interventions that fell into these domains and were published between January 2007 and May 2013. Two reviewers abstracted information and categorized studies by intervention type. Results We identified 60 studies, of which 40% focused on patient education. Other intervention types included augmented pharmacy services, decision aids, shared decision-making, and clinical review of patient adherence. Medication adherence was an outcome in most (70%) of the studies, although 50% also examined patient-centered outcomes. Conclusions We identified a large number of medication management interventions that incorporated patient-centered care and improved patient outcomes. We were unable to determine whether these interventions are more effective than traditional medication adherence interventions. Practice Implications Additional research is needed to identify effective and feasible approaches to incorporate patient-centeredness into the medication management processes of the current health care system, if appropriate. PMID:25264309

An information and communication technology-based centralized clinical trial to determine the efficacy and safety of insulin dose adjustment education based on a smartphone personal health record application: a randomized controlled trial.

PubMed

Kim, Gyuri; Bae, Ji Cheol; Yi, Byoung Kee; Hur, Kyu Yeon; Chang, Dong Kyung; Lee, Moon-Kyu; Kim, Jae Hyeon; Jin, Sang-Man

2017-07-18

A Personal Health Record (PHR) is an online application that allows patients to access, manage, and share their health data. PHRs not only enhance shared decision making with healthcare providers, but also enable remote monitoring and at-home-collection of detailed data. The benefits of PHRs can be maximized in insulin dose adjustment for patients starting or intensifying insulin regimens, as frequent self-monitoring of glucose, self-adjustment of insulin dose, and precise at-home data collection during the visit-to-visit period are important for glycemic control. The aim of this study is to examine the efficacy and safety of insulin dose adjustment based on a smartphone PHR application in patients with diabetes mellitus (DM) and to confirm the validity and stability of an information and communication technology (ICT)-based centralized clinical trial monitoring system. This is a 24-week, open-label, randomized, multi-center trial. There are three follow-up measures: baseline, post-intervention at week 12, and at week 24. Subjects diagnosed with type 1 DM, type 2 DM, and/or post-transplant DM who initiate basal insulin or intensify their insulin regimen to a basal-bolus regimen are included. After education on insulin dose titration and prevention for hypoglycemia and a 1-week acclimation period, subjects are randomized in a 1:1 ratio to either an ICT-based intervention group or a conventional intervention group. Subjects in the conventional intervention group will save and send their health information to the server via a PHR application, whereas those in ICT-based intervention group will receive additional algorithm-based feedback messages. The health information includes level of blood glucose, insulin dose, details on hypoglycemia, food diary, and step count. The primary outcome will be the proportion of patients who reach an optimal insulin dose within 12 weeks of study enrollment, without severe hypoglycemia or unscheduled clinic visits. This clinical trial will reveal whether insulin dose adjustment based on a smartphone PHR application can facilitate the optimization of insulin doses in patients with DM. In addition, the process evaluation will provide information about the validity and stability of the ICT-based centralized clinical trial monitoring system in this research field. Clinicaltrials.gov NCT 03112343 . Registered on 12 April 2017.

Use of Percutaneous Aspiration Thrombectomy vs. Anticoagulation Therapy to Treat Acute Iliofemoral Venous Thrombosis: 1-year Follow-up Results of a Randomised, Clinical Trial

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cakir, Volkan, E-mail: drvolkancakir@gmail.com; Gulcu, Aytac, E-mail: aytac.gulcu@deu.edu.tr; Akay, Emrah, E-mail: emrahakay@hotmail.com

2014-08-15

PurposeThe purpose of this study was to compare the efficacy of percutaneous aspiration thrombectomy (PAT) followed by standard anticoagulant therapy, with anticoagulation therapy alone, for the treatment of acute proximal lower extremity deep vein thrombosis.MethodsIn this randomised, prospective study, 42 patients with acute proximal iliofemoral deep vein thrombosis documented via Doppler ultrasound examination, were separated into an interventional treatment group (16 males, 5 females, average age 51 years) and a medical treatment group (13 males, 8 females, average age 59 years). In the interventional group, PAT with large-lumen 9-F diameter catheterisation was applied, after initiation of standard anticoagulant therapy. Balloon angioplasty (nmore » 19) and stent implementation (n: 14) were used to treat patients with residual stenosis (>50 %) after PAT. Prophylactic IVC filters were placed in two patients. The thrombus clearance status of the venous system was evaluated by venography. In both the medical and interventional groups, venous patency rates and clinical symptom scores were evaluated at months 1, 3, and 12 after treatment.ResultsDeep venous systems became totally cleared of thrombi in 12 patients treated with PAT. The venous patency rates in month 12 were 57.1 and 4.76 % in the interventional and medical treatment groups, respectively. A statistically significant improvement was observed in clinical symptom scores of the interventional group (PAT) with or without stenting (4.23 ± 0.51 before treatment; 0.81 ± 0.92 at month 12) compared with the medical treatment group (4.00 ± 0.63 before treatment; 2.43 ± 0.67 at month 12). During follow-up, four patients in the medical treatment and one in the interventional group developed pulmonary embolisms.ConclusionsFor treatment of acute deep vein thrombosis, PAT with or without stenting is superior to anticoagulant therapy alone in terms of both ensuring venous patency and improving clinical symptoms. PAT is a safe, inexpensive, and easily performed method of endovascular treatment with a low rate of major complications. Our present findings and literature data suggest that PAT can be used as first-line treatment in proximal deep vein thrombosis patients, especially when thrombolytic treatment is contraindicated.« less

Development of DASH Mobile: a mHealth lifestyle change intervention for the management of hypertension.

PubMed

Mann, Devin M; Kudesia, Valmeek; Reddy, Shivani; Weng, Michael; Imler, Daniel; Quintiliani, Lisa

2013-01-01

Several landmark studies based on the DASH diet have established the effectiveness of a lifestyle approach to blood pressure control that emphasizes a diet rich in fruits and vegetables with moderate portions of low-fat dairy and lean protein along with increased physical activity and reduced sodium intake. However, this evidence base remains underused due feasibility limitations of implementing these intense in-person interventions and poor engagement with desktop computer based versions. Mobile technologies such as smartphones and wireless sensors have the ability to deliver behavioral interventions in-the-moment and with reduced user burden. DASH Mobile is a new mHealth system being developed to deliver this evidence-based lifestyle intervention to hypertensive patients. The system consists of an Android based "app" that facilitates easy tracking of DASH food portions, integrated Bluetooth blood pressure, weight and pedometer monitoring, goal setting, simple data visualizations and multimedia video clips to train patients in the basic concepts of the lifestyle change plan. At present, the system is undergoing usability testing with a pilot clinical trial planned for Spring 2013.

Nutritional intervention as an essential part of multiple sclerosis treatment?

PubMed

Penesová, A; Dean, Z; Kollár, B; Havranová, A; Imrich, R; Vlček, M; Rádiková, Ž

2018-05-10

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the central nervous system. In addition to the genetic, epigenetic and immunological components, various other factors e.g. unhealthy dietary habits play a role in the MS pathogenesis. Dietary intervention is a highly appealing approach, as it presents a simple and relatively low risk method to potentially improve outcomes in patients with brain disorders in order to achieve remission and improvement of clinical status, well-being and life expectancy of patients with MS. The importance of saturated fat intake restriction for the clinical status improvement of MS patients was pointed for the first time in 1950s. Recently, decreased risk of first clinical diagnosis of CNS demyelination associated with higher intake of omega-3 polyunsaturated fatty acids particularly originating from fish was reported. Only few clinical trials have been performed to address the question of the role of dietary intervention, such is e.g. low saturated fat diet in MS treatment. This review summarizes current knowledge about the effect of different dietary approaches (diets low in saturated fat and dietary supplements such as fish oil, lipoic acid, omega-3 polyunsaturated fatty acids, seeds oils, high fiber diet, vitamin D, etc.) on neurological signs, patient's well-being, physical and inflammatory status. So far the results are not conclusive, therefore much more research is needed to confirm and to understand the effectiveness of these dietary interventions in the long term and well defined studies.

Effect of inspiratory muscle training with load compared with sham training on blood pressure in individuals with hypertension: study protocol of a double-blind randomized clinical trial.

PubMed

Posser, Simone Regina; Callegaro, Carine Cristina; Beltrami-Moreira, Marina; Moreira, Leila Beltrami

2016-08-02

Hypertension is a complex chronic condition characterized by elevated arterial blood pressure. Management of hypertension includes non-pharmacologic strategies, which may include techniques that effectively reduce autonomic sympathetic activity. Respiratory exercises improve autonomic control over cardiovascular system and attenuate muscle metaboreflex. Because of these effects, respiratory exercises may be useful to lower blood pressure in subjects with hypertension. This randomized, double-blind clinical trial will test the efficacy of inspiratory muscle training in reducing blood pressure in adults with essential hypertension. Subjects are randomly allocated to intervention or control groups. Intervention consists of inspiratory muscle training loaded with 40 % of maximum inspiratory pressure, readjusted weekly. Control sham intervention consists of unloaded exercises. Systolic and diastolic blood pressures are co-primary endpoint measures assessed with 24 h ambulatory blood pressure monitoring. Secondary outcome measures include cardiovascular autonomic control, inspiratory muscle metaboreflex, cardiopulmonary capacity, and inspiratory muscle strength and endurance. Previously published work suggests that inspiratory muscle training reduces blood pressure in persons with hypertension, but the effectiveness of this intervention is yet to be established. We propose an adequately sized randomized clinical trial to test this hypothesis rigorously. If an effect is found, this study will allow for the investigation of putative mechanisms to mediate this effect, including autonomic cardiovascular control and metaboreflex. ClinicalTrials.gov NCT02275377 . Registered on 30 September 2014.

Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya

PubMed Central

2013-01-01

Background A cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact on the health, disability and quality of life of clients, despite a severe shortage of medicines in the clinics (Jenkins et al. Submitted 2012). As focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transit Rev 4:81–85, 1994), the experiences of the participating clients were explored through qualitative focus group discussions in order to better understand the potential reasons for the improved outcomes in the intervention group. Methods Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 clients from the intervention group clinics where staff had received the training programme, and 10 clients from the control group where staff had not received the training during the earlier randomised controlled trial. Results These focus group discussions suggest that the clients in the intervention group noticed and appreciated enhanced communication, diagnostic and counselling skills in their respective health workers, whereas clients in the control group were aware of the lack of these skills. Confidentiality emerged from the discussions as a significant client concern in relation to the volunteer cadre of community health workers, whose only training comes from their respective primary care health workers. Conclusion Enhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcomes for clients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed. Trial registration ISRCTN 53515024. PMID:23343127

Design and Performance Evaluation of Real-time Endovascular Interventional Surgical Robotic System with High Accuracy.

PubMed

Wang, Kundong; Chen, Bing; Lu, Qingsheng; Li, Hongbing; Liu, Manhua; Shen, Yu; Xu, Zhuoyan

2018-05-15

Endovascular interventional surgery (EIS) is performed under a high radiation environment at the sacrifice of surgeons' health. This paper introduces a novel endovascular interventional surgical robot that aims to reduce radiation to surgeons and physical stress imposed by lead aprons during fluoroscopic X-ray guided catheter intervention. The unique mechanical structure allowed the surgeon to manipulate the axial and radial motion of the catheter and guide wire. Four catheter manipulators (to manipulate the catheter and guide wire), and a control console which consists of four joysticks, several buttons and two twist switches (to control the catheter manipulators) were presented. The entire robotic system was established on a master-slave control structure through CAN (Controller Area Network) bus communication, meanwhile, the slave side of this robotic system showed highly accurate control over velocity and displacement with PID controlling method. The robotic system was tested and passed in vitro and animal experiments. Through functionality evaluation, the manipulators were able to complete interventional surgical motion both independently and cooperatively. The robotic surgery was performed successfully in an adult female pig and demonstrated the feasibility of superior mesenteric and common iliac artery stent implantation. The entire robotic system met the clinical requirements of EIS. The results show that the system has the ability to imitate the movements of surgeons and to accomplish the axial and radial motions with consistency and high-accuracy. Copyright © 2018 John Wiley & Sons, Ltd.

Key influences in the design and implementation of mental health information systems in Ghana and South Africa.

PubMed

Ahuja, S; Mirzoev, T; Lund, C; Ofori-Atta, A; Skeen, S; Kufuor, A

2016-01-01

Strengthening of mental health information systems (MHIS) is essential to monitor and evaluate mental health services in low and middle-income countries. While research exists assessing wider health management information systems, there is limited published evidence exploring the design and implementation of MHIS in these settings. This paper aims to identify and assess the key factors affecting the design and implementation of MHIS, as perceived by the key stakeholders in Ghana and South Africa. We report findings from the Mental Health and Poverty Project, a 5-year research programme implemented within four African countries. The MHIS strengthening in South Africa and Ghana included two related components: intervention and research. The intervention component aimed to strengthen MHIS in the two countries, and the research component aimed to document interventions in each country, including the key influences. Data were collected using semi structured interviews with key stakeholders and reviews of key documents and secondary data from the improved MHIS. We analyzed the qualitative data using a framework approach. Key components of the MHIS intervention involved the introduction of a redesigned patient registration form, entry into computers for analysis every 2 months by clinical managerial staff, and utilization of data in hospital management meetings in three psychiatric hospitals in Ghana; and the introduction of a new set of mental health indicators and related forms and tally sheets at primary care clinics and district hospitals in five districts in the KwaZulu-Natal and Northern Cape provinces in South Africa. Overall, the key stakeholders perceived the MHIS strengthening as an effective intervention in both countries with an enhanced set of indicators in South Africa and introduction of a computerized system in Ghana. Influences on the design and implementation of MHIS interventions in Ghana and South Africa relate to resources, working approaches (including degree of consultations during the design stage and communication during implementation stage) and the low priority of mental health. Although the influencing factors represent similar categories, more influences were identified on MHIS implementation, compared with the design stage. Different influences appear to be related within, and across, the MHIS design and implementation and may reinforce or negate each other thus leading to the multiplier or minimization effects. The wider context, similar to other studies, is important in ensuring the success of such interventions. Future MHIS strengthening interventions can consider three policy implications which emerged from our analysis and experience: enhancing consultations during the intervention design, better consideration of implementation challenges during design, and better recognition of relations between different influences.

Implementation Research Workshop in Argentina: Moving Research into Practice

Cancer.gov

Research on implementation science addresses the level to which health interventions can fit within real-world public health and clinical service systems. The overall goal of the Introduction to Cancer Program Planning and Implementation Research Workshop was to train a critical mass of researchers, program managers, practitioners, and policy makers that can apply the knowledge gained on implementation and dissemination research to promote evidence-based interventions to reduce the cancer burden in the country and globally.

Advances in wearable technology for rehabilitation.

PubMed

Bonato, Paolo

2009-01-01

Assessing the impact of rehabilitation interventions on the real life of individuals is a key element of the decision-making process required to choose a rehabilitation strategy. In the past, therapists and physicians inferred the effectiveness of a given rehabilitation approach from observations performed in a clinical setting and self-reports by patients. Recent developments in wearable technology have provided tools to complement the information gathered by rehabilitation personnel via patient's direct observation and via interviews and questionnaires. A new generation of wearable sensors and systems has emerged that allows clinicians to gather measures in the home and community settings that capture patients' activity level and exercise compliance, the effectiveness of pharmacological interventions, and the ability of patients to perform efficiently specific motor tasks. Available unobtrusive sensors allow clinical personnel to monitor patients' movement and physiological data such as heart rate, respiratory rate, and oxygen saturation. Cell phone technology and the widespread access to the Internet provide means to implement systems designed to remotely monitor patients' status and optimize interventions based on individual responses to different rehabilitation approaches. This chapter summarizes recent advances in the field of wearable technology and presents examples of application of this technology in rehabilitation.

Veterinary interventional oncology: from concept to clinic.

PubMed

Weisse, Chick

2015-08-01

Interventional radiology (IR) involves the use of contemporary imaging modalities to gain access to different structures in order to deliver materials for therapeutic purposes. Veterinarians have been expanding the use of these minimally invasive techniques in animals with a variety of conditions involving all of the major body systems. Interventional oncology (IO) is a growing subspecialty of IR in human medicine used (1) to restore patency to malignant obstructions through endoluminal stenting, (2) to provide dose escalations to tumors without increasing systemic chemotherapy toxicities via superselective transarterial chemotherapy delivery, (3) to stop hemorrhage or reduce blood flow to tumors via transarterial embolization or chemoembolization, and (4) to provide therapies for those cancers with no safe or effective alternative options. This review provides a brief introduction to a few of the techniques currently available to veterinarians for cancer treatment. For each technique, the concept for improved palliation, patient quality of life, or tumor control is presented, followed by the most current veterinary clinical information available. Although promising, more studies will be necessary to determine if veterinary IO will provide the same benefits as has already been demonstrated in oncology care in humans. Copyright © 2015 Elsevier Ltd. All rights reserved.

Severe Imatinib-Associated Skin Rash in Gastrointestinal Stromal Tumor Patients: Management and Clinical Implications.

PubMed

Park, Sook Ryun; Ryu, Min-Hee; Ryoo, Baek-Yeol; Beck, Mo Youl; Lee, In Soon; Choi, Mi Jung; Lee, Mi Woo; Kang, Yoon-Koo

2016-01-01

This study evaluated the incidence of imatinib-associated skin rash, the interventional outcomes of severe rash, and impact of severe rash on the outcomes of imatinib treatment in gastrointestinal stromal tumor (GIST) patients. A total of 620 patients were administered adjuvant or palliative imatinib for GIST at Asan Medical Center between January 2000 and July 2012. This analysis focused on a group of 42 patients who developed a severe rash requiring major interventions, defined as dose interruption or reduction of imatinib or systemic steroid use. Of the 620 patients treated with imatinib, 148 patients (23.9%) developed an imatinib-associated skin rash; 42 patients (6.8%) developed a severe rash requiring major intervention. Of these, 28 patients (66.8%) successfully continued imatinib with interventions. Serial blood eosinophil levels during imatinib treatment were associated with skin rash and severity. A significant association was observed between successful intervention and blood eosinophil level at the time of intervention initiation. In metastatic settings, patients with severe rash requiring major interventions tended to show poorer progression-free survival than patients who did not require major intervention and patients with no rash, although this finding was not statistically significant (p=0.326). By aggressive treatment of severe rash through modification of imatinib dose or use of systemic steroid, the majority of patients can continue on imatinib. In particular, imatinib dose intensity can be maintained with use of systemic steroid. Measuring the blood eosinophil levels may be helpful in guiding the management plan for skin rash regarding the intensity and duration of interventions.

Severe Imatinib-Associated Skin Rash in Gastrointestinal Stromal Tumor Patients: Management and Clinical Implications

PubMed Central

Park, Sook Ryun; Ryu, Min-Hee; Ryoo, Baek-Yeol; Beck, Mo Youl; Lee, In Soon; Choi, Mi Jung; Lee, Mi Woo; Kang, Yoon-Koo

2016-01-01

Purpose This study evaluated the incidence of imatinib-associated skin rash, the interventional outcomes of severe rash, and impact of severe rash on the outcomes of imatinib treatment in gastrointestinal stromal tumor (GIST) patients. Materials and Methods A total of 620 patients were administered adjuvant or palliative imatinib for GIST at Asan Medical Center between January 2000 and July 2012. This analysis focused on a group of 42 patients who developed a severe rash requiring major interventions, defined as dose interruption or reduction of imatinib or systemic steroid use. Results Of the 620 patients treated with imatinib, 148 patients (23.9%) developed an imatinib-associated skin rash; 42 patients (6.8%) developed a severe rash requiring major intervention. Of these, 28 patients (66.8%) successfully continued imatinib with interventions. Serial blood eosinophil levels during imatinib treatment were associated with skin rash and severity. A significant association was observed between successful intervention and blood eosinophil level at the time of intervention initiation. In metastatic settings, patients with severe rash requiring major interventions tended to show poorer progression-free survival than patients who did not require major intervention and patients with no rash, although this finding was not statistically significant (p=0.326). Conclusion By aggressive treatment of severe rash through modification of imatinib dose or use of systemic steroid, the majority of patients can continue on imatinib. In particular, imatinib dose intensity can be maintained with use of systemic steroid. Measuring the blood eosinophil levels may be helpful in guiding the management plan for skin rash regarding the intensity and duration of interventions. PMID:26323636

Effects of short-term addition of NSAID to diuretics and/or RAAS-inhibitors on blood pressure and renal function.

PubMed

Nygård, Peder; Jansman, Frank G A; Kruik-Kollöffel, Willemien J; Barnaart, Alex F W; Brouwers, Jacobus R B J

2012-06-01

The combined post-operative use of diuretics and/or renin-angiotensin-aldosterone system (RAAS) inhibitors may increase the risk of nonsteroidal anti-inflammatory drug (NSAID) associated renal failure because of a drug-drug interaction. The aim of this study was to investigate the effect of the short-term (<4 days) post-operative combined use of NSAIDs with diuretics and/or RAAS inhibitors on renal function and blood pressure. One teaching hospital in the Netherlands. The study-design was a prospective, observational cohort-study. Based on postoperative treatment with NSAIDs, the intervention-group was compared to a control-group (no NSAIDs treatment). Systolic blood pressure and renal function expressed by the estimated glomular filtration rate (eGFR) calculated with the modification of renal desease formula. 97 patients were included in the intervention-group, 53 patients in the control-group. Patient characteristics were comparable except for one variable: 'combined use of a diuretic with a RAAS inhibitor' which was higher in the control-group (62 vs. 43 %, p = 0.046). Odds ratio for clinically relevant increase in systolic blood pressure was 0.66 (CI95 % 0.3-1.5). Odds ratio for clinical relevant decrease in renal function was 2.44 (CI95 % 1.1-5.2). On day 4 eGFR of 3 patients in the intervention- and 1 in the control-group was <50 ml/min/1.73 m(2). Odds ratios showed no significant difference of a clinically relevant increase in systolic blood pressure but showed a higher risk for a clinically relevant decrease in renal function in the intervention group. However this decrease resulted in a relevant impaired renal function (<50 ml/min/1.73 m(2)) in only 3 patients in the interventiongroup and 1 patient in the control-group. In the post-operative patient, without preexisting impaired renal function, concurrent diuretics and/or renin-angiotensinaldosterone system inhibitor therapy can be combined with short-term NSAID treatment.

Ethnographic process evaluation in primary care: explaining the complexity of implementation.

PubMed

Bunce, Arwen E; Gold, Rachel; Davis, James V; McMullen, Carmit K; Jaworski, Victoria; Mercer, MaryBeth; Nelson, Christine

2014-12-05

The recent growth of implementation research in care delivery systems has led to a renewed interest in methodological approaches that deliver not only intervention outcome data but also deep understanding of the complex dynamics underlying the implementation process. We suggest that an ethnographic approach to process evaluation, when informed by and integrated with quantitative data, can provide this nuanced insight into intervention outcomes. The specific methods used in such ethnographic process evaluations are rarely presented in detail; our objective is to stimulate a conversation around the successes and challenges of specific data collection methods in health care settings. We use the example of a translational clinical trial among 11 community clinics in Portland, OR that are implementing an evidence-based, health-information technology (HIT)-based intervention focused on patients with diabetes. Our ethnographic process evaluation employed weekly diaries by clinic-based study employees, observation, informal and formal interviews, document review, surveys, and group discussions to identify barriers and facilitators to implementation success, provide insight into the quantitative study outcomes, and uncover lessons potentially transferable to other implementation projects. These methods captured the depth and breadth of factors contributing to intervention uptake, while minimizing disruption to clinic work and supporting mid-stream shifts in implementation strategies. A major challenge is the amount of dedicated researcher time required. The deep understanding of the 'how' and 'why' behind intervention outcomes that can be gained through an ethnographic approach improves the credibility and transferability of study findings. We encourage others to share their own experiences with ethnography in implementation evaluation and health services research, and to consider adapting the methods and tools described here for their own research.

Pre-Visit Prioritization for Complex Patients with Diabetes: Randomized Trial Design and Implementation within an Integrated Health Care System

PubMed Central

Grant, Richard W; Uratsu, Connie S; Hansen, Karen R; Altschuler, Andrea; Kim, Eileen; Fireman, Bruce; Adams, Alyce S; Schmittdiel, Julie A; Heisler, Michele

2016-01-01

Background/Aims Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. Methods We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system. Results This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015 – 6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) Navigating research vs. quality improvement requirements; (2) Addressing informed consent considerations; and (3) Introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for “self-learning health system” research. Conclusions By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations. PMID:26820612

Clinical relevance of gait research applied to clinical trials in spinal cord injury.

PubMed

Ditunno, John; Scivoletto, Giorgio

2009-01-15

The restoration of walking function following SCI is extremely important to consumers and has stimulated a response of new treatments by scientists, the pharmaceutical industry and clinical entrepreneurs. Several of the proposed interventions: (1) the use of functional electrical stimulation (FES) and (2) locomotor training have been examined in clinical trials and recent reviews of the scientific literature. Each of these interventions is based on research of human locomotion. Therefore, the systematic study of walking function and gait in normal individuals and those with injury to the spinal cord has contributed to the identification of the impairments of walking, the development of new treatments and how they will be measured to determine effectiveness. In this context gait research applied to interventions to improve walking function is of high clinical relevance. This research helps identify walking impairments to be corrected and measures of walking function to be utilized as endpoints for clinical trials. The most common impairments following SCI diagnosed by observational gait analysis include inadequate hip extension during stance, persistent plantar flexion and hip/knee flexion during swing and foot placement at heel strike. FES has been employed as one strategy for correcting these impairments based on analysis that range from simple measures of speed, cadence and stride length to more sophisticated systems of three- dimensional video motion analysis and multichannel EMG tracings of integrated walking. A recent review of the entire FES literature identified 36 studies that merit comment and the full range of outcome measures for walking function were used from simple velocity to the video analysis of motion. In addition to measures of walking function developed for FES interventions, the first randomized multicenter clinical trial on locomotor training in subacute SCI was recently published with an extensive review of these measures. In this study outcome measures of motor strength (impairment), balance, Walking Index for SCI (WISCI), speed, 5min walk (walking capacities) and locomotor functional independence measure (L-FIM), a disability measure all showed improvement in walking function based on the strategy of the response of activity based plasticity to step training. Although the scientific basis for this intervention will be covered in other articles in this series, the evolution of clinical outcome measures of walking function continues to be important for the determination of effectiveness in clinical trials.

Whole-flock, metaphylactic tilmicosin failed to eliminate contagious ovine digital dermatitis and footrot in sheep: a cluster randomised trial.

PubMed

Angell, J W; Grove-White, D H; Williams, H J; Duncan, J S

2016-09-24

The aim of this study was to evaluate the clinical success of whole-flock systemic tilmicosin and enhanced biosecurity in eliminating active contagious ovine digital dermatitis (CODD) from sheep flocks. Thirty flocks in the UK were randomly allocated to receive either treatment as usual (as per the farmer's normal routine) or whole-flock treatment with tilmicosin, together with isolation and extended treatment of clinically affected individuals and isolation and treatment of purchased sheep during the study period. All flocks were visited once at onset of the trial to examine all sheep. One year later, all sheep were re-examined to determine the presence/absence of clinical lesions. The primary outcome was the clinical elimination of CODD from flocks. Secondary outcomes were reduction in prevalence of CODD, clinical elimination of footrot and reduction in prevalence of footrot. The analysis included 11 control flocks and 13 intervention flocks, with initially 3460 and 4686 sheep, respectively. For CODD: at follow-up, in the intervention group, 6/13 (46 per cent) flocks had a prevalence of zero compared with 1/11 (9 per cent) in the control group (P=0.12). For footrot: at follow-up, no flocks had a prevalence of zero. Therefore, the intervention is not recommended for the elimination of CODD or footrot in the UK. British Veterinary Association.

Whole-flock, metaphylactic tilmicosin failed to eliminate contagious ovine digital dermatitis and footrot in sheep: a cluster randomised trial

PubMed Central

Angell, J. W.; Grove-White, D. H.; Williams, H. J.; Duncan, J. S.

2016-01-01

The aim of this study was to evaluate the clinical success of whole-flock systemic tilmicosin and enhanced biosecurity in eliminating active contagious ovine digital dermatitis (CODD) from sheep flocks. Thirty flocks in the UK were randomly allocated to receive either treatment as usual (as per the farmer's normal routine) or whole-flock treatment with tilmicosin, together with isolation and extended treatment of clinically affected individuals and isolation and treatment of purchased sheep during the study period. All flocks were visited once at onset of the trial to examine all sheep. One year later, all sheep were re-examined to determine the presence/absence of clinical lesions. The primary outcome was the clinical elimination of CODD from flocks. Secondary outcomes were reduction in prevalence of CODD, clinical elimination of footrot and reduction in prevalence of footrot. The analysis included 11 control flocks and 13 intervention flocks, with initially 3460 and 4686 sheep, respectively. For CODD: at follow-up, in the intervention group, 6/13 (46 per cent) flocks had a prevalence of zero compared with 1/11 (9 per cent) in the control group (P=0.12). For footrot: at follow-up, no flocks had a prevalence of zero. Therefore, the intervention is not recommended for the elimination of CODD or footrot in the UK. PMID:27450091

Clinical Effects of Cigarette Smoking: Epidemiologic Impact and Review of Pharmacotherapy Options

PubMed Central

Onor, IfeanyiChukwu O.; Stirling, Daniel L.; Williams, Shandrika R.; Bediako, Daniel; Borghol, Amne; Harris, Martha B.; Darensburg, Tiernisha B.; Clay, Sharde D.; Okpechi, Samuel C.; Sarpong, Daniel F.

2017-01-01

Cigarette smoking—a crucial modifiable risk factor for organ system diseases and cancer—remains prevalent in the United States and globally. In this literature review, we aim to summarize the epidemiology of cigarette smoking and tobacco use in the United States, pharmacology of nicotine—the active constituent of tobacco, and health consequence of cigarette smoking. This article also reviews behavioral and pharmacologic interventions for cigarette smokers and provides cost estimates for approved pharmacologic interventions in the United States. A literature search was conducted on Google Scholar, EBSCOhost, ClinicalKey, and PubMed databases using the following headings in combination or separately: cigarette smoking, tobacco smoking, epidemiology in the United States, health consequences of cigarette smoking, pharmacologic therapy for cigarette smoking, and non-pharmacologic therapy for cigarette smoking. This review found that efficacious non-pharmacologic interventions and pharmacologic therapy are available for cessation of cigarette smoking. Given the availability of efficacious interventions for cigarette smoking cessation, concerted efforts should be made by healthcare providers and public health professionals to promote smoking cessation as a valuable approach for reducing non-smokers’ exposure to environmental tobacco smoke. PMID:28956852

Automating individualized coaching and authentic role-play practice for brief intervention training.

PubMed

Hayes-Roth, B; Saker, R; Amano, K

2010-01-01

Brief intervention helps to reduce alcohol abuse, but there is a need for accessible, cost-effective training of clinicians. This study evaluated STAR Workshop , a web-based training system that automates efficacious techniques for individualized coaching and authentic role-play practice. We compared STAR Workshop to a web-based, self-guided e-book and a no-treatment control, for training the Engage for Change (E4C) brief intervention protocol. Subjects were medical and nursing students. Brief written skill probes tested subjects' performance of individual protocol steps, in different clinical scenarios, at three test times: pre-training, post-training, and post-delay (two weeks). Subjects also did live phone interviews with a standardized patient, post-delay. STAR subjects performed significantly better than both other groups. They showed significantly greater improvement from pre-training probes to post-training and post-delay probes. They scored significantly higher on post-delay phone interviews. STAR Workshop appears to be an accessible, cost-effective approach for training students to use the E4C protocol for brief intervention in alcohol abuse. It may also be useful for training other clinical interviewing protocols.

An update on the clinical use of drug-coated balloons in percutaneous coronary interventions.

PubMed

Cheng, Yanping; Leon, Martin B; Granada, Juan F

2016-06-01

Drug-coated balloons (DCB) promise to deliver anti-proliferative drugs and prevent restenosis leaving nothing behind. Although, randomized clinical trials have demonstrated their efficacy for the treatment of in-stent restenosis, clinical evidence supporting their use in other coronary applications is still lacking. This review summarizes the development status of clinically available DCB technologies and provides an update on the current data for their coronary use. Current generation DCB prevent restenosis by delivering paclitaxel particles on the surface of the vessel wall. Although clinically available technologies share a common mechanism of action, important differences in pharmacokinetic behavior and safety profiles do exist. Future technological improvements include the development of coatings displaying: high transfer efficiency; low particle embolization potential; and alternative drug formulations. Optimized balloon-based delivery systems and drug encapsulation technologies also promise to improve the technical limitations of current generation DCB. Although proving clinical superiority against DES may prove to be difficult in mainstream applications (i.e., de novo), new generation DCB technologies have the potential to achieve a strong position in the interventional field in clinical settings in which the efficacy of DES use is not proven or justified (i.e., bifurcations).

PRODIACOR: a patient-centered treatment program for type 2 diabetes and associated cardiovascular risk factors in the city of Corrientes, Argentina: study design and baseline data.

PubMed

Gagliardino, J J; Lapertosa, S; Villagra, M; Caporale, J E; Oliver, P; Gonzalez, C; Siri, F; Clark, Ch

2007-07-01

To implement a controlled clinical trial (PRODIACOR) in a primary care setting designed 1) to improve type 2 diabetes care and 2) to collect cost data in order to be able to measure cost-effectiveness of three system interventions (checkbook of indicated procedures, patient/provider feedback and complete coverage of medications and supplies) and physician and/or patient education to improve psychological, clinical, metabolic and therapeutic indicators. All three Argentinean health subsectors (public health, social security and the private, prepaid system) are participants in the study. Patients of participating physicians were randomly selected and assigned to one of four groups: control, provider education, patient education, and provider/patient education; the system interventions were provided to all four groups. Mean BMI was 29.8 kg/m(2); most subjects had blood pressure, fasting glucose and total cholesterol above targets recommended by international standards. Only 1% had had microalbuminuria measured, 57% performed glucose self-monitoring, 37% had had an eye examination and 31% a foot examination in the preceding year. Ten percent, 26% and 73% of people with hyperglycemia, hypertension and dyslipidemia, respectively, were not on medications. Most patients treated with either insulin or oral antidiabetic agents were on monotherapy as were those treated for hypertension and dyslipidemia. WHO-5 questionnaire scores indicated that 13% of the subjects needed psychological intervention. Baseline data show multiple deficiencies in the process and outcomes of care that could be targeted and improved by PRODIACOR intervention.

Prefrontal mediation of the reading network predicts intervention response in dyslexia.

PubMed

Aboud, Katherine S; Barquero, Laura A; Cutting, Laurie E

2018-04-01

A primary challenge facing the development of interventions for dyslexia is identifying effective predictors of intervention response. While behavioral literature has identified core cognitive characteristics of response, the distinction of reading versus executive cognitive contributions to response profiles remains unclear, due in part to the difficulty of segregating these constructs using behavioral outputs. In the current study we used functional neuroimaging to piece apart the mechanisms of how/whether executive and reading network relationships are predictive of intervention response. We found that readers who are responsive to intervention have more typical pre-intervention functional interactions between executive and reading systems compared to nonresponsive readers. These findings suggest that intervention response in dyslexia is influenced not only by domain-specific reading regions, but also by contributions from intervening domain-general networks. Our results make a significant gain in identifying predictive bio-markers of outcomes in dyslexia, and have important implications for the development of personalized clinical interventions. Copyright © 2018 Elsevier Ltd. All rights reserved.

Using engineering control principles to inform the design of adaptive interventions: a conceptual introduction.

PubMed

Rivera, Daniel E; Pew, Michael D; Collins, Linda M

2007-05-01

The goal of this paper is to describe the role that control engineering principles can play in developing and improving the efficacy of adaptive, time-varying interventions. It is demonstrated that adaptive interventions constitute a form of feedback control system in the context of behavioral health. Consequently, drawing from ideas in control engineering has the potential to significantly inform the analysis, design, and implementation of adaptive interventions, leading to improved adherence, better management of limited resources, a reduction of negative effects, and overall more effective interventions. This article illustrates how to express an adaptive intervention in control engineering terms, and how to use this framework in a computer simulation to investigate the anticipated impact of intervention design choices on efficacy. The potential benefits of operationalizing decision rules based on control engineering principles are particularly significant for adaptive interventions that involve multiple components or address co-morbidities, situations that pose significant challenges to conventional clinical practice.

Using Engineering Control Principles to Inform the Design of Adaptive Interventions: A Conceptual Introduction

PubMed Central

Rivera, Daniel E.; Pew, Michael D.; Collins, Linda M.

2007-01-01

The goal of this paper is to describe the role that control engineering principles can play in developing and improving the efficacy of adaptive, time-varying interventions. It is demonstrated that adaptive interventions constitute a form of feedback control system in the context of behavioral health. Consequently, drawing from ideas in control engineering has the potential to significantly inform the analysis, design, and implementation of adaptive interventions, leading to improved adherence, better management of limited resources, a reduction of negative effects, and overall more effective interventions. This article illustrates how to express an adaptive intervention in control engineering terms, and how to use this framework in a computer simulation to investigate the anticipated impact of intervention design choices on efficacy. The potential benefits of operationalizing decision rules based on control engineering principles are particularly significant for adaptive interventions that involve multiple components or address co-morbidities, situations that pose significant challenges to conventional clinical practice. PMID:17169503

Economic evaluation of three populational screening strategies for cervical cancer in the county of Valles Occidental: CRICERVA clinical trial

PubMed Central

2011-01-01

Background A high percentage of cervical cancer cases have not undergone cytological tests within 10 years prior to diagnosis. Different population interventions could improve coverage in the public system, although costs will also increase. The aim of this study was to compare the effectiveness and the costs of three types of population interventions to increase the number of female participants in the screening programmes for cancer of the cervix carried out by Primary Care in four basic health care areas. Methods/Design A cost-effectiveness analysis will be performed from the perspective of public health system including women from 30 to 70 years of age (n = 20,994) with incorrect screening criteria from four basic health care areas in the Valles Occidental, Barcelona, Spain. The patients will be randomly distributed into the control group and the three intervention groups (IG1: invitation letter to participate in the screening; IG2: invitation letter and informative leaflet; IG3: invitation letter, informative leaflet and a phone call reminder) and followed for three years. Clinical effectiveness will be measured by the number of HPV, epithelial lesions and cancer of cervix cases detected. The number of deaths avoided will be secondary measures of effectiveness. The temporal horizon of the analysis will be the life expectancy of the female population in the study. Costs and effectiveness will be discounted at 3%. In addition, univariate and multivariate sensitivity analysis will be carried out. Discussion IG3 is expected to be more cost-effective intervention than IG1 and IG2, with greater detection of HPV infections, epithelial lesions and cancer than other strategies, albeit at a greater cost. Trial Registration Clinical Trials.gov Identifier NCT01373723 PMID:22011387

Barriers and facilitators to the implementation of antenatal syphilis screening and treatment for the prevention of congenital syphilis in the Democratic Republic of Congo and Zambia: results of qualitative formative research.

PubMed

Nkamba, Dalau; Mwenechanya, Musaku; Kilonga, Arlette Mavila; Cafferata, Maria Luisa; Berrueta, Amanda Mabel; Mazzoni, Agustina; Althabe, Fernando; Garcia-Elorrio, Ezequiel; Tshefu, Antoniette K; Chomba, Elwyn; Buekens, Pierre M; Belizan, Maria

2017-08-14

The impact of untreated syphilis during pregnancy on neonatal health remains a major public health threat worldwide. Given the high prevalence of syphilis during pregnancy in Zambia and Democratic Republic of Congo (DRC), the Preventive Congenital Syphilis Trial (PCS Trial), a cluster randomized trial, was proposed to increase same-day screening and treatment of syphilis during antenatal care visits. To design an accepted and feasible intervention, we conducted a qualitative  formative research. Our objective was to identify context-specific  barriers and facilitators to the implementation of antenatal screening and treatment during pregnancy. Qualitative research included in-depth semi-structured interviews with clinic administrators, group interviews with health care providers, and focus groups with pregnant women in primary care clinics (PCCs) in Kinshasa (DRC) and Lusaka (Zambia). A total of 112 individuals participated in the interviews and focus groups. Barriers for the implementation of syphilis testing and treatment were identified at the a) system level: fragmentation of the health system, existence of ANC guidelines in conflict with proposed intervention, poor accessibility of clinics (geographical and functional), staff and product shortages at the PCCs; b) healthcare providers' level: lack of knowledge and training about evolving best practices, reservations regarding same-day screening and treatment; c) Pregnant women level: late enrollment in ANC, lack of knowledge about consequences and treatment of syphilis, and stigma. Based on these results, we developed recommendations for the design of the PCS Trial intervention. This research allowed us to identify barriers and facilitators to improve the feasibility and acceptability of a behavioral intervention. Formative research is a critical step in designing appropriate and effective interventions by closing the "know-do gap".

A mixed methods feasibility study to evaluate the use of a low-intensity, nurse-delivered cognitive behavioural therapy for the treatment of irritable bowel syndrome.

PubMed

Dainty, Andrew David; Fox, Mark; Lewis, Nina; Hunt, Melissa; Holtham, Elizabeth; Timmons, Stephen; Kinsella, Philip; Wragg, Andrew; Callaghan, Patrick

2014-06-17

Irritable bowel syndrome (IBS) is characterised by symptoms such as abdominal pain, constipation, diarrhoea and bloating. These symptoms impact on health-related quality of life, result in excess service utilisation and are a significant burden to healthcare systems. Certain mechanisms which underpin IBS can be explained by a biopsychosocial model which is amenable to psychological treatment using techniques such as cognitive behavioural therapy (CBT). While current evidence supports CBT interventions for this group of patients, access to these treatments within the UK healthcare system remains problematic. A mixed methods feasibility randomised controlled trial will be used to assess the feasibility of a low-intensity, nurse-delivered guided self-help intervention within secondary care gastrointestinal clinics. A total of 60 participants will be allocated across four treatment conditions consisting of: high-intensity CBT delivered by a fully qualified cognitive behavioural therapist, low-intensity guided self-help delivered by a registered nurse, self-help only without therapist support and a treatment as usual control condition. Participants from each of the intervention arms of the study will be interviewed in order to identify potential barriers and facilitators to the implementation of CBT interventions within clinical practice settings. Quantitative data will be analysed using descriptive statistics only. Qualitative data will be analysed using a group thematic analysis. This study will provide essential information regarding the feasibility of nurse-delivered CBT interventions within secondary care gastrointestinal clinics. The data gathered during this study would also provide useful information when planning a substantive trial and will assist funding bodies when considering investment in substantive trial funding. A favourable opinion for this research was granted by the Nottingham 2 Research Ethics Committee. 83683687 (http://www.controlled-trials.com/ISRCTN83683687). Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Chemical Interventions for Pain.

ERIC Educational Resources Information Center

Aronoff, Gerald M.; And Others

1986-01-01

Reviews properties and pharmacological effects of medications for pain, including peripherally acting analgesics, centrally acting narcotics, and adjuvant analgesics including antidepressants. Discusses the role of the endogenous opioid system in pain and depression. Explores clinical management issues in both inpatient and outpatient settings,…

Computerised mirror therapy with Augmented Reflection Technology for early stroke rehabilitation: clinical feasibility and integration as an adjunct therapy.

PubMed

Hoermann, Simon; Ferreira Dos Santos, Luara; Morkisch, Nadine; Jettkowski, Katrin; Sillis, Moran; Devan, Hemakumar; Kanagasabai, Parimala S; Schmidt, Henning; Krüger, Jörg; Dohle, Christian; Regenbrecht, Holger; Hale, Leigh; Cutfield, Nicholas J

2017-07-01

New rehabilitation strategies for post-stroke upper limb rehabilitation employing visual stimulation show promising results, however, cost-efficient and clinically feasible ways to provide these interventions are still lacking. An integral step is to translate recent technological advances, such as in virtual and augmented reality, into therapeutic practice to improve outcomes for patients. This requires research on the adaptation of the technology for clinical use as well as on the appropriate guidelines and protocols for sustainable integration into therapeutic routines. Here, we present and evaluate a novel and affordable augmented reality system (Augmented Reflection Technology, ART) in combination with a validated mirror therapy protocol for upper limb rehabilitation after stroke. We evaluated components of the therapeutic intervention, from the patients' and the therapists' points of view in a clinical feasibility study at a rehabilitation centre. We also assessed the integration of ART as an adjunct therapy for the clinical rehabilitation of subacute patients at two different hospitals. The results showed that the combination and application of the Berlin Protocol for Mirror Therapy together with ART was feasible for clinical use. This combination was integrated into the therapeutic plan of subacute stroke patients at the two clinical locations where the second part of this research was conducted. Our findings pave the way for using technology to provide mirror therapy in clinical settings and show potential for the more effective use of inpatient time and enhanced recoveries for patients. Implications for Rehabilitation Computerised Mirror Therapy is feasible for clinical use Augmented Reflection Technology can be integrated as an adjunctive therapeutic intervention for subacute stroke patients in an inpatient setting Virtual Rehabilitation devices such as Augmented Reflection Technology have considerable potential to enhance stroke rehabilitation.

Cost Effectiveness of Adopted Quality Requirements in Hospital Laboratories

PubMed Central

HAMZA, Alneil; AHMED-ABAKUR, Eltayib; ABUGROUN, Elsir; BAKHIT, Siham; HOLI, Mohamed

2013-01-01

Background The present study was designed in quasi-experiment to assess adoption of the essential clauses of particular clinical laboratory quality management requirements based on international organization for standardization (ISO 15189) in hospital laboratories and to evaluate the cost effectiveness of compliance to ISO 15189. Methods: The quality management intervention based on ISO 15189 was conceded through three phases; pre – intervention phase, Intervention phase and Post-intervention phase. Results: In pre-intervention phase the compliance to ISO 15189 was 49% for study group vs. 47% for control group with P value 0.48, while the post intervention results displayed 54% vs. 79% for study group and control group respectively in compliance to ISO 15189 and statistically significant difference (P value 0.00) with effect size (Cohen’s d) of (0.00) in pre-intervention phase and (0.99) in post – intervention phase. The annual average cost per-test for the study group and control group was 1.80 ± 0.25 vs. 1.97 ± 0.39, respectively with P value 0.39 whereas the post-intervention results showed that the annual average total costs per-test for study group and control group was 1.57 ± 0.23 vs 2.08 ± 0.38, P value 0.019 respectively, with cost-effectiveness ratio of (0.88) in pre -intervention phase and (0.52) in post-intervention phase. Conclusion: The planned adoption of quality management requirements (QMS) in clinical laboratories had great effect to increase the compliance percent with quality management system requirement, raise the average total cost effectiveness, and improve the analytical process capability of the testing procedure. PMID:23967422

A novel open-source drug-delivery system that allows for first-of-kind simulation of nonadherence to pharmacological interventions in animal disease models.

PubMed

Thomson, Kyle E; White, H Steve

2014-12-30

Nonadherence to a physician-prescribed therapeutic intervention is a costly, dangerous, and sometimes fatal concern in healthcare. To date, the study of nonadherence has been constrained to clinical studies. The novel approach described herein allows for the preclinical study of nonadherence in etiologically relevant disease animal model systems. The method herein describes a novel computer-automated pellet delivery system which allows for the study of nonadherence in animals. This system described herein allows for tight experimenter control of treatment using a drug-in-food protocol. Food-restricted animals receive either medicated or unmedicated pellets, designed to mimic either "taking" or "missing" a drug. The system described permits the distribution of medicated or unmedicated food pellets on an experimenter-defined feeding schedule. The flexibility of this system permits the delivery of drug according to the known pharmacokinetics of investigational drugs. Current clinical adherence research relies on medication-event monitoring system (MEMS) tracking caps, which allows clinicians to directly monitor patient adherence. However, correlating the effects of nonadherence to efficacy still relies on the accuracy of patient journals. This system allows for the design of studies to address the impact of nonadherence in an etiologically relevant animal model. Given methodological and ethical concerns of designing clinical studies of nonadherence, animal studies are critical to better understand medication adherence. While the system described was designed to measure the impact of nonadherence on seizure control, it is clear that the utility of this system extends beyond epilepsy to include other disease states. Copyright © 2014 Elsevier B.V. All rights reserved.

Implementing tobacco use treatment guidelines in public health dental clinics in New York City.

PubMed

Shelley, Donna; Anno, Jaime; Tseng, Tuo-Yen; Calip, Greg; Wedeles, John; Lloyd, Madeleine; Wolff, Mark S

2011-04-01

In this study we evaluated the effect of a multicomponent intervention to implement the Public Health Service (PHS) guideline Treating Tobacco Use and Dependence in six randomly selected dental clinics in New York University's College of Dentistry. The main outcome measure-provider adherence to tobacco use treatment guidelines-was assessed by auditing a random selection of patient charts pre (698) and post (641) intervention. The intervention components included a chart reminder and referral system, free nicotine replacement therapy (NRT), and provider training and feedback. The results showed that rates of screening for tobacco use did not change between pre and post test chart audits. However, providers were significantly more likely to offer advice (28.4 percent pre, 49 percent post), assess readiness to quit (17.8 percent pre, 29.9 percent post), and offer assistance (6.5 percent pre and 15.6 percent post) in the post test period. Increases in NRT distribution were associated with booster training sessions but declined in the time periods between those trainings. Research is needed to further define sustainable strategies for implementing tobacco use treatment in dental clinics. The results of this study suggest the feasibility and effectiveness of using a tailored multicomponent approach to implement tobacco use treatment guidelines in dental clinics.

Clinician attitudes, social norms and intentions to use a computer-assisted intervention.

PubMed

Buti, Allison L; Eakins, Danielle; Fussell, Holly; Kunkel, Lynn E; Kudura, Aisha; McCarty, Dennis

2013-04-01

The National Drug Abuse Treatment Clinical Trials Network (CTN) works to bridge the gap between research and practice and tested a Web-delivered psychosocial intervention (the Therapeutic Education System, TES) in 10 community treatment centers. Computer-assisted therapies, such as Web-delivered interventions, may improve the consistency and efficiency of treatment for alcohol and drug use disorders. Prior to the start of the study, we surveyed counselors (N=96) in participating treatment centers and assessed counselor attitudes, perceived social norms and intentions to use a Web-delivered intervention. Analysis of the intention to adopt a Web-delivered intervention assessed the influence of attitudes and perceived social norms. Perceived social norms were a significant contributor to clinician intention to adopt Web-based interventions while attitude was not. To promote successful implementation, it may be helpful to create social norms supportive of computer-assisted therapies. Copyright © 2013 Elsevier Inc. All rights reserved.

Interventions to Increase Male Attendance and Testing for Sexually Transmitted Infections at Publicly-Funded Family Planning Clinics.

PubMed

Fine, David; Warner, Lee; Salomon, Sarah; Johnson, David M

2017-07-01

We assessed the impact of staff, clinic, and community interventions on male and female family planning client visit volume and sexually transmitted infection testing at a multisite community-based health care agency. Staff training, clinic environmental changes, in-reach/outreach, and efficiency assessments were implemented in two Family Health Center (San Diego, CA) family planning clinics during 2010-2012; five Family Health Center family planning programs were identified as comparison clinics. Client visit records were compared between preintervention (2007-2009) and postintervention (2010-2012) for both sets of clinics. Of 7,826 male client visits during the time before intervention, most were for clients who were aged <30 years (50%), Hispanic (64%), and uninsured (81%). From preintervention to postintervention, intervention clinics significantly increased the number of male visits (4,004 to 8,385; Δ = +109%); for comparison clinics, male visits increased modestly (3,822 to 4,500; Δ = +18%). The proportion of male clinic visits where chlamydia testing was performed increased in intervention clinics (35% to 42%; p < .001) but decreased in comparison clinics (37% to 33%; p < .001). Subgroup analyses conducted among adolescent and young adult males yielded similar findings for male client volume and chlamydia testing. The number of female visits declined nearly 40% in both comparison (21,800 to 13,202; -39%) and intervention clinics (30,830 to 19,971; -35%) between preintervention and postintervention periods. Multilevel interventions designed to increase male client volume and sexually transmitted infection testing services in family planning clinics succeeded without affecting female client volume or services. Copyright © 2017 Society for Adolescent Health and Medicine. All rights reserved.

Clinical applications of penetrating neural interfaces and Utah Electrode Array technologies

NASA Astrophysics Data System (ADS)

Normann, Richard A.; Fernandez, Eduardo

2016-12-01

This paper briefly describes some of the recent progress in the development of penetrating microelectrode arrays and highlights the use of two of these devices, Utah electrode arrays and Utah slanted electrode arrays, in two therapeutic interventions: recording volitional skeletal motor commands from the central nervous system, and recording motor commands and evoking somatosensory percepts in the peripheral nervous system (PNS). The paper also briefly explores other potential sites for microelectrode array interventions that could be profitably pursued and that could have important consequences in enhancing the quality of life of patients that has been compromised by disorders of the central and PNSs.

Patient-specific computer-based decision support in primary healthcare--a randomized trial.

PubMed

Kortteisto, Tiina; Raitanen, Jani; Komulainen, Jorma; Kunnamo, Ilkka; Mäkelä, Marjukka; Rissanen, Pekka; Kaila, Minna

2014-01-20

Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice. However, evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems. In Finland, we designed a trial where a set of evidence-based, patient-specific reminders was introduced into the local Electronic Patient Record (EPR) system. The aim was to measure the effects of such reminders on patient care. The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group, indicating an improvement in patient care. From July 2009 to October 2010 all the patients of one health center were randomized to an intervention or a control group. The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional (HCP) opened and used the EPR. In the intervention group, the triggered reminders were shown to the HCP; in the control group, the triggered reminders were not shown. The primary outcome measure was the change in the number of reminders triggered over 12 months. We developed a unique data gathering method, the Repeated Study Virtual Health Check (RSVHC), and used Generalized Estimation Equations (GEE) for analysing the incidence rate ratio, which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group. In total, 13,588 participants were randomized and included. Contrary to our expectation, the total number of reminders triggered increased in both the intervention and the control groups. The primary outcome measure did not show a significant difference between the groups. However, with the inclusion of patients followed up over only six months, the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors (age, gender, number of diagnoses and medications) were controlled for. Computerized, tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system. ClinicalTrial.gov NCT00915304.

“Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention”

PubMed Central

2013-01-01

Background We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers. Methods The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011. Results Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year. Conclusions The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision. PMID:23566021

Admission Privileges and Clinical Responsibilities for Interventional Radiologists

DOE Office of Scientific and Technical Information (OSTI.GOV)

Al-Kutoubi, Aghiad, E-mail: mk00@aub.edu.lb

2015-04-15

Although clinical involvement by interventional radiologists in the care of their patients was advocated at the inception of the specialty, the change into the clinical paradigm has been slow and patchy for reasons related to pattern of practice, financial remuneration or absence of training. The case for the value of clinical responsibilities has been made in a number of publications and the consequences of not doing so have been manifest in the erosion of the role of the interventional radiologists particularly in the fields of peripheral vascular and neuro intervention. With the recent recognition of interventional radiology (IR) as amore » primary specialty in the USA and the formation of IR division in the Union of European Medical Specialists and subsequent recognition of the subspecialty in many European countries, it is appropriate to relook at the issue and emphasize the need for measures to promote the clinical role of the interventional radiologist.« less

Impact of an emergency department electronic sepsis surveillance system on patient mortality and length of stay.

PubMed

Austrian, Jonathan S; Jamin, Catherine T; Doty, Glenn R; Blecker, Saul

2018-05-01

The purpose of this study was to determine whether an electronic health record-based sepsis alert system could improve quality of care and clinical outcomes for patients with sepsis. We performed a patient-level interrupted time series study of emergency department patients with severe sepsis or septic shock between January 2013 and April 2015. The intervention, introduced in February 2014, was a system of interruptive sepsis alerts triggered by abnormal vital signs or laboratory results. Primary outcomes were length of stay (LOS) and in-hospital mortality; other outcomes included time to first lactate and blood cultures prior to antibiotics. We also assessed sensitivity, positive predictive value (PPV), and clinician response to the alerts. Mean LOS for patients with sepsis decreased from 10.1 to 8.6 days (P < .001) following alert introduction. In adjusted time series analysis, the intervention was associated with a decreased LOS of 16% (95% CI, 5%-25%; P = .007, with significance of α = 0.006) and no change thereafter (0%; 95% CI, -2%, 2%). The sepsis alert system had no effect on mortality or other clinical or process measures. The intervention had a sensitivity of 80.4% and a PPV of 14.6%. Alerting based on simple laboratory and vital sign criteria was insufficient to improve sepsis outcomes. Alert fatigue due to the low PPV is likely the primary contributor to these results. A more sophisticated algorithm for sepsis identification is needed to improve outcomes.

Interdisciplinary Systems-Based Intervention to Improve IV Hydration during Parenteral Administration of Acyclovir.

PubMed

Dubrofsky, Lisa; Kerzner, Ryan S; Delaunay, Chloë; Kolenda, Camille; Pepin, Jocelyne; Schwartz, Blair C

2016-01-01

Intravenous (IV) hydration is considered a protective factor in reducing the incidence of acyclovir-induced nephrotoxicity. A systems-based review of cases of acyclovir-associated acute kidney injury can be used to examine institution-, care provider-, and task-related factors involved in administering the drug and can serve as a basis for developing a quality improvement intervention to achieve safer administration of acyclovir. To explore the effectiveness of the study institution's inter-disciplinary quality improvement intervention in increasing the dilution of acyclovir before IV administration. After conducting a systems-based review for intervention development, a retrospective analysis was undertaken to compare IV administration of acyclovir in the 6-month periods before and after implementation of the intervention. The study population was a sequential sample of all patients over 18 years of age who were seen in the emergency department or admitted to a ward and who received at least one IV dose of acyclovir at the study institution. The primary outcome was the volume in which each acyclovir dose was delivered. The secondary outcomes were the hourly rate of fluid administration, the frequency of an increase in hourly hydration rate, and the incidence of acute kidney injury. Eighty-four patients (44 in the pre-intervention period and 40 in the post-intervention period) received IV acyclovir and had evaluable data for the primary outcome. The median volume in which the acyclovir dose was administered was significantly higher in the post-intervention group (250 mL versus 100 mL, p < 0.001). In this study, an easily implemented intervention significantly increased the volume of IV fluid administered to patients receiving acyclovir. Adequately powered prospective studies are suggested to investigate the effectiveness of this intervention on the clinically relevant incidence of acyclovir-induced nephrotoxicity.

Health Education and Symptom Flare Management Using a Video-Based m-Health System for Caring Women with IC/BPS.

PubMed

Lee, Ming-Huei; Wu, Huei-Ching; Tseng, Chien-Ming; Ko, Tsung-Liang; Weng, Tang-Jun; Chen, Yung-Fu

2018-06-10

To assess effectiveness of the video-based m-health system providing videos dictated by physicians for health education and symptom self-management for patients with IC/BPS. An m-health system was designed to provide videos for weekly health education and symptom flare self-management. O'Leary-Sant index and VAS scale as well as SF-36 health survey were administrated to evaluate the disease severity and quality of life (QoL), respectively. A total of 60 IC/BPS patients were recruited and randomly assigned to either control group (30 patients) or study group (30 patients) in sequence depending on their orders to visit our urological clinic. Patients in both control and study groups received regular treatments, while those in the study group received additional video-based intervention. Statistical analyses were conducted to compare the outcomes between baseline and post-intervention for both groups. The outcomes of video-based intervention were also compared with the text-based intervention conducted in our previous study. After video-based intervention, patients in the study group exhibited significant effect manifested in all disease severity and QoL assessments except the VAS pain scale, while no significance was found in the control group. Moreover, the study group exhibited more significant net improvements than the control group in 7 SF-36 constructs, except the mental health. The limitations include short intervention duration (8 weeks) and different study periods between text-based and video-based interventions. Video-based intervention is effective in improving the QoL of IC/BPS patients and outperforms the text-based intervention even in a short period of intervention. Copyright © 2018. Published by Elsevier Inc.

Model based LV-reconstruction in bi-plane x-ray angiography

NASA Astrophysics Data System (ADS)

Backfrieder, Werner; Carpella, Martin; Swoboda, Roland; Steinwender, Clemens; Gabriel, Christian; Leisch, Franz

2005-04-01

Interventional x-ray angiography is state of the art in diagnosis and therapy of severe diseases of the cardiovascular system. Diagnosis is based on contrast enhanced dynamic projection images of the left ventricle. A new model based algorithm for three dimensional reconstruction of the left ventricle from bi-planar angiograms was developed. Parametric super ellipses are deformed until their projection profiles optimally fit measured ventricular projections. Deformation is controlled by a simplex optimization procedure. A resulting optimized parameter set builds the initial guess for neighboring slices. A three dimensional surface model of the ventricle is built from stacked contours. The accuracy of the algorithm has been tested with mathematical phantom data and clinical data. Results show conformance with provided projection data and high convergence speed makes the algorithm useful for clinical application. Fully three dimensional reconstruction of the left ventricle has a high potential for improvements of clinical findings in interventional cardiology.

Understanding the dispensary workflow at the Birmingham Free Clinic: a proposed framework for an informatics intervention.

PubMed

Fisher, Arielle M; Herbert, Mary I; Douglas, Gerald P

2016-02-19

The Birmingham Free Clinic (BFC) in Pittsburgh, Pennsylvania, USA is a free, walk-in clinic that serves medically uninsured populations through the use of volunteer health care providers and an on-site medication dispensary. The introduction of an electronic medical record (EMR) has improved several aspects of clinic workflow. However, pharmacists' tasks involving medication management and dispensing have become more challenging since EMR implementation due to its inability to support workflows between the medical and pharmaceutical services. To inform the design of a systematic intervention, we conducted a needs assessment study to identify workflow challenges and process inefficiencies in the dispensary. We used contextual inquiry to document the dispensary workflow and facilitate identification of critical aspects of intervention design specific to the user. Pharmacists were observed according to contextual inquiry guidelines. Graphical models were produced to aid data and process visualization. We created a list of themes describing workflow challenges and asked the pharmacists to rank them in order of significance to narrow the scope of intervention design. Three pharmacists were observed at the BFC. Observer notes were documented and analyzed to produce 13 themes outlining the primary challenges pharmacists encounter during dispensation at the BFC. The dispensary workflow is labor intensive, redundant, and inefficient when integrated with the clinical service. Observations identified inefficiencies that may benefit from the introduction of informatics interventions including: medication labeling, insufficient process notification, triple documentation, and inventory control. We propose a system for Prescription Management and General Inventory Control (RxMAGIC). RxMAGIC is a framework designed to mitigate workflow challenges and improve the processes of medication management and inventory control. While RxMAGIC is described in the context of the BFC dispensary, we believe it will be generalizable to pharmacies in other low-resource settings, both domestically and internationally.

Improving outcomes of first‐episode psychosis: an overview

PubMed Central

Fusar‐Poli, Paolo; McGorry, Patrick D.; Kane, John M.

2017-01-01

Outcomes of psychotic disorders are associated with high personal, familiar, societal and clinical burden. There is thus an urgent clinical and societal need for improving those outcomes. Recent advances in research knowledge have opened new opportunities for ameliorating outcomes of psychosis during its early clinical stages. This paper critically reviews these opportunities, summarizing the state‐of‐the‐art knowledge and focusing on recent discoveries and future avenues for first episode research and clinical interventions. Candidate targets for primary universal prevention of psychosis at the population level are discussed. Potentials offered by primary selective prevention in asymptomatic subgroups (stage 0) are presented. Achievements of primary selected prevention in individuals at clinical high risk for psychosis (stage 1) are summarized, along with challenges and limitations of its implementation in clinical practice. Early intervention and secondary prevention strategies at the time of a first episode of psychosis (stage 2) are critically discussed, with a particular focus on minimizing the duration of untreated psychosis, improving treatment response, increasing patients’ satisfaction with treatment, reducing illicit substance abuse and preventing relapses. Early intervention and tertiary prevention strategies at the time of an incomplete recovery (stage 3) are further discussed, in particular with respect to addressing treatment resistance, improving well‐being and social skills with reduction of burden on the family, treatment of comorbid substance use, and prevention of multiple relapses and disease progression. In conclusion, to improve outcomes of a complex, heterogeneous syndrome such as psychosis, it is necessary to globally adopt complex models integrating a clinical staging framework and coordinated specialty care programmes that offer pre‐emptive interventions to high‐risk groups identified across the early stages of the disorder. Only a systematic implementation of these models of care in the national health care systems will render these strategies accessible to the 23 million people worldwide suffering from the most severe psychiatric disorders. PMID:28941089

GaitaBase: Web-based repository system for gait analysis.

PubMed

Tirosh, Oren; Baker, Richard; McGinley, Jenny

2010-02-01

The need to share gait analysis data to improve clinical decision support has been recognised since the early 1990s. GaitaBase has been established to provide a web-accessible repository system of gait analysis data to improve the sharing of data across local and international clinical and research community. It is used by several clinical and research groups across the world providing cross-group access permissions to retrieve and analyse the data. The system is useful for bench-marking and quality assurance, clinical consultation, and collaborative research. It has the capacity to increase the population sample size and improve the quality of 'normative' gait data. In addition the accumulated stored data may facilitate clinicians in comparing their own gait data with others, and give a valuable insight into how effective specific interventions have been for others. 2009 Elsevier Ltd. All rights reserved.

Strategies and Opportunities to STOP Colon Cancer in Priority Populations: Design of a Cluster-Randomized Pragmatic Trial

PubMed Central

Coronado, Gloria D.; Vollmer, William M.; Petrik, Amanda; Taplin, Stephen H.; Burdick, Timothy E.; Meenan, Richard T.; Green, Beverly

2014-01-01

Background Colorectal cancer is the second-leading cause of cancer deaths in the United States. The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) in Priority Populations study is a pragmatic trial and a collaboration between two research institutions and a network of more than 200 safety net clinics. The study will assess effectiveness of a systems-based intervention designed to improve rates of colorectal-cancer screening using fecal immunochemical testing (FIT) in federally qualified health centers in Oregon and Northern California. Material and Methods STOP CRC is a cluster-randomized comparative-effectiveness pragmatic trial enrolling 26 clinics. Clinics will be randomized to one of two arms. Clinics in the intervention arm (1) will use an automated, data-driven, electronic health record-embedded program to identify patients due for colorectal screening and mail FIT kits (with pictographic instructions) to them; (2) will conduct an improvement process (e.g. Plan-Do-Study-Act) to enhance the adoption, reach, and effectiveness of the program. Clinics in the control arm will provide opportunistic colorectal-cancer screening to patients at clinic visits. The primary outcomes are: proportion of age– and screening-eligible patients completing a FIT within 12 months; and cost, cost-effectiveness, and return on investment of the intervention. Conclusions This large-scale pragmatic trial will leverage electronic health record information and existing clinic staff to enroll a broad range of patients, including many with historically low colorectal-cancer screening rates. If successful, the program will provide a model for a cost-effective and scalable method to raise colorectal-cancer screening rates. PMID:24937017

Computer-supported feedback message tailoring: theory-informed adaptation of clinical audit and feedback for learning and behavior change.

PubMed

Landis-Lewis, Zach; Brehaut, Jamie C; Hochheiser, Harry; Douglas, Gerald P; Jacobson, Rebecca S

2015-01-21

Evidence shows that clinical audit and feedback can significantly improve compliance with desired practice, but it is unclear when and how it is effective. Audit and feedback is likely to be more effective when feedback messages can influence barriers to behavior change, but barriers to change differ across individual health-care providers, stemming from differences in providers' individual characteristics. The purpose of this article is to invite debate and direct research attention towards a novel audit and feedback component that could enable interventions to adapt to barriers to behavior change for individual health-care providers: computer-supported tailoring of feedback messages. We argue that, by leveraging available clinical data, theory-informed knowledge about behavior change, and the knowledge of clinical supervisors or peers who deliver feedback messages, a software application that supports feedback message tailoring could improve feedback message relevance for barriers to behavior change, thereby increasing the effectiveness of audit and feedback interventions. We describe a prototype system that supports the provision of tailored feedback messages by generating a menu of graphical and textual messages with associated descriptions of targeted barriers to behavior change. Supervisors could use the menu to select messages based on their awareness of each feedback recipient's specific barriers to behavior change. We anticipate that such a system, if designed appropriately, could guide supervisors towards giving more effective feedback for health-care providers. A foundation of evidence and knowledge in related health research domains supports the development of feedback message tailoring systems for clinical audit and feedback. Creating and evaluating computer-supported feedback tailoring tools is a promising approach to improving the effectiveness of clinical audit and feedback.

Using the collaborative intervention planning framework to adapt a health-care manager intervention to a new population and provider group to improve the health of people with serious mental illness.

PubMed

Cabassa, Leopoldo J; Gomes, Arminda P; Meyreles, Quisqueya; Capitelli, Lucia; Younge, Richard; Dragatsi, Dianna; Alvarez, Juana; Manrique, Yamira; Lewis-Fernández, Roberto

2014-11-30

Health-care manager interventions improve the physical health of people with serious mental illness (SMI) and could be widely implemented in public mental health clinics. Local adaptations and customization may be needed to increase the reach of these interventions in the public mental health system and across different racial and ethnic communities. In this study, we describe how we used the collaborative intervention planning framework to customize an existing health-care manager intervention to a new patient population (Hispanics with SMI) and provider group (social workers) to increase its fit with our local community. The study was conducted in partnership with a public mental health clinic that serves predominantly Hispanic clients. A community advisory board (CAB) composed of researchers and potential implementers (e.g., social workers, primary care physicians) used the collaborative intervention planning framework, an approach that combines community-based participatory research principles and intervention mapping (IM) procedures, to inform intervention adaptations. The adaptation process included four steps: fostering collaborations between CAB members; understanding the needs of the local population through a mixed-methods needs assessment, literature reviews, and group discussions; reviewing intervention objectives to identify targets for adaptation; and developing the adapted intervention. The application of this approach enabled the CAB to identify a series of cultural and provider level-adaptations without compromising the core elements of the original health-care manager intervention. Reducing health disparities in people with SMI requires community engagement, particularly when preparing existing interventions to be used with new communities, provider groups, and practice settings. Our study illustrates one approach that can be used to involve community stakeholders in the intervention adaptation process from the very beginning to enhance the transportability of a health-care manager intervention in order to improve the health of people with SMI.

Endoscopic optical coherence tomography: technologies and clinical applications [Invited

PubMed Central

Gora, Michalina J.; Suter, Melissa J.; Tearney, Guillermo J.; Li, Xingde

2017-01-01

In this paper, we review the current state of technology development and clinical applications of endoscopic optical coherence tomography (OCT). Key design and engineering considerations are discussed for most OCT endoscopes, including side-viewing and forward-viewing probes, along with different scanning mechanisms (proximal-scanning versus distal-scanning). Multi-modal endoscopes that integrate OCT with other imaging modalities are also discussed. The review of clinical applications of endoscopic OCT focuses heavily on diagnosis of diseases and guidance of interventions. Representative applications in several organ systems are presented, such as in the cardiovascular, digestive, respiratory, and reproductive systems. A brief outlook of the field of endoscopic OCT is also discussed. PMID:28663882

Provider and systems factors in diabetes quality of care.

PubMed

Ghaznavi, Kimia; Malik, Shaista

2012-02-01

A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.

Can Robotic Interaction Improve Joint Attention Skills?

PubMed Central

Zheng, Zhi; Swanson, Amy R.; Bekele, Esubalew; Zhang, Lian; Crittendon, Julie A.; Weitlauf, Amy F.; Sarkar, Nilanjan

2013-01-01

Although it has often been argued that clinical applications of advanced technology may hold promise for addressing impairments associated with autism spectrum disorder (ASD), relatively few investigations have indexed the impact of intervention and feedback approaches. This pilot study investigated the application of a novel robotic interaction system capable of administering and adjusting joint attention prompts to a small group (n = 6) of children with ASD. Across a series of four sessions, children improved in their ability to orient to prompts administered by the robotic system and continued to display strong attention toward the humanoid robot over time. The results highlight both potential benefits of robotic systems for directed intervention approaches as well as potent limitations of existing humanoid robotic platforms. PMID:24014194

Can Robotic Interaction Improve Joint Attention Skills?

PubMed

Warren, Zachary E; Zheng, Zhi; Swanson, Amy R; Bekele, Esubalew; Zhang, Lian; Crittendon, Julie A; Weitlauf, Amy F; Sarkar, Nilanjan

2015-11-01

Although it has often been argued that clinical applications of advanced technology may hold promise for addressing impairments associated with autism spectrum disorder (ASD), relatively few investigations have indexed the impact of intervention and feedback approaches. This pilot study investigated the application of a novel robotic interaction system capable of administering and adjusting joint attention prompts to a small group (n = 6) of children with ASD. Across a series of four sessions, children improved in their ability to orient to prompts administered by the robotic system and continued to display strong attention toward the humanoid robot over time. The results highlight both potential benefits of robotic systems for directed intervention approaches as well as potent limitations of existing humanoid robotic platforms.

Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians.

PubMed

Wu, Robert C; Tran, Kim; Lo, Vivian; O'Leary, Kevin J; Morra, Dante; Quan, Sherman D; Perrier, Laure

2012-11-01

To conduct a systematic review of the literature to identify, describe and assess interventions of information and communication technology on the processes of communication and associated patient outcomes within hospital settings. Studies published from the years 1996 to 2010 were considered and were selected if they described an evaluation of information and communication technology interventions to improve clinical communication within hospitals. Two authors abstracted data from full text articles, and the quality of individual articles were appraised. Results of interventions were summarized by their effect. There were 18 identified studies that evaluated the use of interventions that included alphanumeric paging, hands-free communication devices, mobile phones, smartphones, task management systems and a display based paging system. Most quantitative studies used a before and after study design and were of lower quality. Of all the studies, there was only one prospective randomized study, but this study used only simulated communication events. Quantitative studies identified improved perceptions of communication and some improvement in communication metrics. Qualitative studies described improvements in efficiency of communication but also issues of loss of control and reliability. Despite the rapid advancement in information and communications technology over the last decade, there is limited evidence suggesting improvements in the ability of health professionals to communicate effectively. Given the critical nature of communication, we advocate further evaluation of information and communication technology designed to improve communication between clinicians. Outcome measures should include measures of patient-oriented outcomes and efficiency for clinicians. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre.

PubMed

Eaton, Kevin P; Chida, Natasha; Apfel, Ariella; Feldman, Leonard; Greenbaum, Adena; Tuddenham, Susan; Kendall, Emily A; Pahwa, Amit

2018-06-01

The near-universal prevalence of electronic health records (EHRs) has made the utilization of clinical decision support systems (CDSS) an integral strategy for improving the value of laboratory ordering. Few studies have examined the effectiveness of nonintrusive CDSS on inpatient laboratory utilization in large academic centres. Red blood cell folate, hepatitis C virus viral loads and genotypes, and type and screens were selected for study. We incorporated the appropriate indications for these labs into text that accompanied the laboratory orders in our hospital's EHR. Providers could proceed with the order without additional clicks. An interrupted time-series analysis was performed, and the primary outcome was the rate of tests ordered on all inpatient medicine floors. The rate of folate tests ordered per monthly admissions showed no significant level change at the time of the intervention with only a slight decrease in rate of 0.0109 (P = .07). There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions immediately after the intervention with a decrease of 0.0135 tests per monthly admissions (P = .02). The rate of type and screens orders per patient days each month had a significant downward trend by 0.114 before the intervention (P = .04) but no significant level change at the time of the intervention or significant change in rate after the intervention. Our study suggests that nonintrusive CDSS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue. © 2018 John Wiley & Sons, Ltd.

A pilot test of a tailored mobile and web-based diabetes messaging system for adolescents.

PubMed

Mulvaney, Shelagh A; Anders, Shilo; Smith, Annie K; Pittel, Eric J; Johnson, Kevin B

2012-03-01

We conducted a pilot trial of a new mobile and web-based intervention to improve diabetes adherence. The text messaging system was designed to motivate and remind adolescents about diabetes self-care tasks. Text messages were tailored according to individually-reported barriers to diabetes self-care. A total of 23 adolescents with type 1 diabetes used the system for a period of three months. On average, they received 10 text messages per week (range 8-12). A matched historical control group from the same clinic was used for comparison. After three months, system users rated the content, usability and experiences with the system, which were very favourable. Comparison of the intervention and control groups indicated a significant interaction between group and time. Both groups had similar HbA(1c) levels at baseline. After three months, the mean HbA(1c) level in the intervention group was unchanged (8.8%), but the mean level in the control group was significantly higher (9.9%), P = 0.006. The results demonstrate the feasibility of the messaging system, user acceptance and a promising effect on glycaemic control. Integrating this type of messaging system with online educational programming could prove to be beneficial.

Tobacco use disorder treatment in primary care

PubMed Central

Kunyk, Diane; Els, Charl; Papadakis, Sophia; Selby, Peter

2014-01-01

Abstract Objective To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. Design A prospective cohort study. Setting Sixty primary care sites in Alberta. Participants A convenience sample of 198 primary care physicians from the population of 2857. Main outcome measures Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians’ treatment intentions, and patient chart reviews examined changes in physicians’ consistency with the treatment algorithm. Results The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. Conclusion Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians’ practices. PMID:25022640

Clinical relevance of pharmacist intervention in an emergency department.

PubMed

Pérez-Moreno, Maria Antonia; Rodríguez-Camacho, Juan Manuel; Calderón-Hernanz, Beatriz; Comas-Díaz, Bernardino; Tarradas-Torras, Jordi

2017-08-01

To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity. A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient. During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001). In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review.

PubMed

Cummings, Amanda; Lund, Susi; Campling, Natasha; May, Carl R; Richardson, Alison; Myall, Michelle

2017-10-06

To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration. A scoping review was undertaken based on the methodological framework of Arksey and O'Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes. Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal. A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pain medication management processes used by oncology outpatients and family caregivers part I: health systems contexts.

PubMed

Schumacher, Karen L; Plano Clark, Vicki L; West, Claudia M; Dodd, Marylin J; Rabow, Michael W; Miaskowski, Christine

2014-11-01

Oncology patients with persistent pain treated in outpatient settings and their family caregivers have significant responsibility for managing pain medications. However, little is known about their practical day-to-day experiences with pain medication management. The aim was to describe day-to-day pain medication management from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial of a psychoeducational intervention called the Pro-Self(©) Plus Pain Control Program. In this article, we focus on pain medication management by patients and family caregivers in the context of multiple complex health systems. We qualitatively analyzed audio-recorded intervention sessions that included extensive dialogue between patients, family caregivers, and nurses about pain medication management during the 10-week intervention. The health systems context for pain medication management included multiple complex systems for clinical care, reimbursement, and regulation of analgesic prescriptions. Pain medication management processes particularly relevant to this context were getting prescriptions and obtaining medications. Responsibilities that fell primarily to patients and family caregivers included facilitating communication and coordination among multiple clinicians, overcoming barriers to access, and serving as a final safety checkpoint. Significant effort was required of patients and family caregivers to insure safe and effective pain medication management. Health systems issues related to access to needed analgesics, medication safety in outpatient settings, and the effort expended by oncology patients and their family caregivers require more attention in future research and health-care reform initiatives. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Development and implementation of an integrated chronic disease model in South Africa: lessons in the management of change through improving the quality of clinical practice

PubMed Central

Asmall, Shaidah

2015-01-01

Background South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge. Methods The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model. Results The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes. Conclusion The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process. PMID:26528101

Development and implementation of an integrated chronic disease model in South Africa: lessons in the management of change through improving the quality of clinical practice.

PubMed

Mahomed, Ozayr Haroon; Asmall, Shaidah

2015-01-01

South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge. The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model. The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes. The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process.

A systems medicine research approach for studying alcohol addiction.

PubMed

Spanagel, Rainer; Durstewitz, Daniel; Hansson, Anita; Heinz, Andreas; Kiefer, Falk; Köhr, Georg; Matthäus, Franziska; Nöthen, Markus M; Noori, Hamid R; Obermayer, Klaus; Rietschel, Marcella; Schloss, Patrick; Scholz, Henrike; Schumann, Gunter; Smolka, Michael; Sommer, Wolfgang; Vengeliene, Valentina; Walter, Henrik; Wurst, Wolfgang; Zimmermann, Uli S; Stringer, Sven; Smits, Yannick; Derks, Eske M

2013-11-01

According to the World Health Organization, about 2 billion people drink alcohol. Excessive alcohol consumption can result in alcohol addiction, which is one of the most prevalent neuropsychiatric diseases afflicting our society today. Prevention and intervention of alcohol binging in adolescents and treatment of alcoholism are major unmet challenges affecting our health-care system and society alike. Our newly formed German SysMedAlcoholism consortium is using a new systems medicine approach and intends (1) to define individual neurobehavioral risk profiles in adolescents that are predictive of alcohol use disorders later in life and (2) to identify new pharmacological targets and molecules for the treatment of alcoholism. To achieve these goals, we will use omics-information from epigenomics, genetics transcriptomics, neurodynamics, global neurochemical connectomes and neuroimaging (IMAGEN; Schumann et al. ) to feed mathematical prediction modules provided by two Bernstein Centers for Computational Neurosciences (Berlin and Heidelberg/Mannheim), the results of which will subsequently be functionally validated in independent clinical samples and appropriate animal models. This approach will lead to new early intervention strategies and identify innovative molecules for relapse prevention that will be tested in experimental human studies. This research program will ultimately help in consolidating addiction research clusters in Germany that can effectively conduct large clinical trials, implement early intervention strategies and impact political and healthcare decision makers. © 2013 Society for the Study of Addiction.

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare.

PubMed

Liberati, Elisa G; Peerally, Mohammad Farhad; Dixon-Woods, Mary

2018-02-01

Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare. Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH). A range of clinical settings in four English NHS hospitals. The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC. Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed. © The Author(s) 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care.