| 51. |
- Gurung, Rejina, et al.
(författare)
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Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN)-a stepped wedge cluster randomized controlled trial in public hospitals.
- 2019
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Ingår i: Implementation science : IS. - : Springer Science and Business Media LLC. - 1748-5908. ; 14:1
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Tidskriftsartikel (refereegranskat)abstract
- Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement package-Scaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)-on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2 months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19 months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo®) and neonatal heart rate monitors (Neobeat®) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations.With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings.ISRCTN16741720 . Registered on 2 March 2019.
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| 52. |
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| 53. |
- Hasson, Henna, et al.
(författare)
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Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives : a study protocol
- 2018
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Ingår i: Implementation Science. - : BIOMED CENTRAL LTD. - 1748-5908. ; 13
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Tidskriftsartikel (refereegranskat)abstract
- Background: A considerable proportion of interventions provided to patients lacks evidence of their effectiveness This implies that patients may receive ineffective, unnecessary, or even harmful care Thus, in addition to implementing evidence based practices, there is also a need to abandon interventions that are not based on best evidence, i e, low value care However, research on de implementation is limited, and there is a lack of knowledge about how effective de implementation processes should be earned out The aim of this project is to explore the phenomenon of the de implementation of low value health care practices from the perspective of professionals and the health care system. Methods: Theories of habits and developmental learning in combination with theories of organizational alignment will be used The project's work will be conducted in five steps Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de implementation In Step 4, a conceptual framework for de implementation will be developed based on the previous steps In Step 5, strategies for de implementation are identified using a co design approach. Discussion: This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de implementation of low value care The professionals' perspectives will be highlighted, including insights into how they make decisions, handle de implementation in daily practice, and what consequences it has on their work Furthermore, the health care system perspective will be considered and new knowledge on how de implementation can be understood across health care system levels will be obtained The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact The project employs a solution oriented perspective by developing a framework for de implementation of low value practices and suggesting practical strategies to improve de implementation processes at all levels of the health care system The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.
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| 54. |
- Hasson, H., et al.
(författare)
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To do or not to do - Balancing governance and professional autonomy to abandon low-value practices : A study protocol
- 2019
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Ingår i: Implementation Science. - : BioMed Central Ltd.. - 1748-5908. ; 14:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations. Methods: Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance. Discussion: This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.
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| 55. |
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| 56. |
- Högberg, Ulf, 1949-
(författare)
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Transfer of knowledge to diagnose infant abuse and its incidence : a time-series analysis from Sweden
- 2022
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Ingår i: Implementation Science. - : BioMed Central. - 1748-5908. ; 17:1
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Tidskriftsartikel (refereegranskat)abstract
- AIM: To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault).METHODS: Design: retrospective population-based and quasi-experimental.SETTING: Sweden 1987-2019.PATIENTS: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm.MAIN OUTCOME MEASURE: Abuse diagnoses (maltreatment or assault).ANALYSES: Incidence rate, incidence rate ratio (IRR). RESULTS: The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987-2019. It was rather stable 1987-2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002-2007, peaking in 2008-2013 [IRR 1.63 (95% confidence interval 1.34-1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014-2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71-0.99)].CONCLUSION: An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process.
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| 57. |
- Ingvarsson, Sara, et al.
(författare)
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Strategies for de-implementation of low-value care—a scoping review
- 2022
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Ingår i: Implementation Science. - : BioMed Central Ltd. - 1748-5908. ; 17:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method: A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results: The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions: Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.
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| 58. |
- Ingvarsson, S., et al.
(författare)
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Why do they do it? : A grounded theory study of the use of low-value care among primary health care physicians
- 2020
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Ingår i: Implementation Science. - : BioMed Central Ltd. - 1748-5908. ; 15:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods: Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results: Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions: Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.
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| 59. |
- Kalkan, Almina, et al.
(författare)
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Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study
- 2014
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Ingår i: Implementation Science. - : BioMed Central. - 1748-5908. ; 9:153
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Tidskriftsartikel (refereegranskat)abstract
- Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.
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| 60. |
- Keurhorst, M., et al.
(författare)
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Impact of primary healthcare providers' initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial
- 2016
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Ingår i: Implementation Science. - : Springer Science and Business Media LLC. - 1748-5908. ; 11
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Tidskriftsartikel (refereegranskat)abstract
- Background: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. Methods: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. Results: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. Conclusions: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners' attitudes, their actual behaviour and care improvement strategies to enhance implementation science.
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