Journal of evaluation in clinical practice最新文献

Introduction: The objective of this study was to assess the impact of the Enhanced Recovery After Surgery (ERAS) programme implementation on treatment costs at a university-type centre, using the DRG scheme.

Materials and methods: Retrospective analysis of patients' data in a group of 604 individuals enroled in the study. We evaluated three groups of patients according to the ERAS clinical protocol (CP): (1) CP oncogynaecology, (2) CP simple hysterectomy, (3) CP laparoscopy. The study aimed to evaluate the impact on the length of stay (LOS), savings in bed-days, and the reduction in direct treatment costs. Three parameters-antibiotic consumption, blood derivative consumption and laboratory test costs-were chosen to compare direct treatment costs. The statistical significance of the difference in the observed parameters was tested by a two-sample unpaired t test with unequal variances at the 0.05 significance level.

Results: We analysed data from 604 patients. In all three groups, the length of stay (LOS) was significantly reduced. The most significant reduction was observed in the CP oncogynaecology group, where the LOS was reduced from 11.1 days to 6.8 days (2022) and 7.6 days (2023) compared to 2019 (p < 0.05). Furthermore, there was a notable reduction in inpatient bed-days, which resulted in the capacity being made available to admit additional patients. A statistically significant reduction in direct costs was observed in the group of CP hysterectomy (antibiotic use) and in the CP laparoscopy (laboratory test costs).

Conclusions: The implementation of the ERAS principles resulted in a number of significant positive economic impacts-reduction in the LOS and a corresponding increase in bed capacity for new patients. Additionally, direct treatment costs, including those related to antibiotic use or laboratory testing were reduced. The Czech Republic's acute healthcare system, like the majority of European healthcare systems, is financed by the DRG system. This flat-rate payment per patient encourages hospital management to seek cost-reduction strategies. The results of our study indicate that fast-track protocols represent a potential viable approach to reducing the cost of treatment while simultaneously meeting the recommendations of evidence-based medicine.

Aim: To investigate the current status of stigma in patients with rheumatoid arthritis (RA), and its correlation with treatment adherence and quality of life.

Methods: The convenience sample of 266 patients diagnosed with RA was surveyed at the rheumatology and immunology outpatient department of a tertiary hospital in Jiangsu Province from May 2022 to September 2022. In addition to this, 20 RA patients were purposively sampled for semi-structured in-depth interviews, and the data were analysed using content analysis methods.

Results: The total stigma's score of the 266 participants was (47.8 ± 10.8), which indicates a moderate level of stigma. The mean scores for alienation, stereotype endorsement, perceived discrimination, and social withdrawal were (2.2 ± 0.7), (2.4 ± 0.7), (2.9 ± 0.6), and (2.2 ± 0.6) respectively. A comparison of the average family monthly income, family roles, duration, disease activity, duration of morning stiffness, visual analogue scale score, C-reactive protein, erythrocyte sedimentation rate, and total stigma score revealed significant differences (p < 0.05). The total treatment adherence score was negatively correlated with the total stigma's score and scores in each dimension (p < 0.05). Similarly, the total psychological health score and total physical health score were negatively correlated with the total stigma score and scores in each dimension (p < 0.05). The qualitative study identified six themes: self-denial, discrimination, lack of disease-related knowledge, high medical costs, increased life burden and resistance to stigma.

Conclusion: Stigma affects RA patients' treatment adherence and quality of life negatively. Healthcare workers are advised to develop comprehensive intervention programs that address the current status of stigma, with the aim of controlling disease progression, reducing disability rates, and improving the quality of life for RA patients.

Objective: To examine the early effects of the financial incentive (FI) implemented in April 2022 in Japan for surgeries within 48 h after hip fracture (HF) in patients aged 75 and older on expedited HF surgery (EHFS), in-hospital mortality, perioperative morbidity, length of stay (LOS) and inpatient medical expenses (IMEs).

Study setting and design: We conducted a quasi-experimental study and constructed segmented regression models for controlled interrupted time-series analyses, assuming a Poisson distribution, to evaluate the slope changes (SCs) in the outcomes of interest before and after the introduction of the FI.

Data sources and analytic sample: We used Diagnosis Procedure Combination data from the Quality Indicator/Improvement Project database between 1 April 2018 and 31 March 2023. Patients aged 50 years or older who were hospitalized with a diagnosis of HF and underwent surgery for HF were included.

Principal findings: A total of 82,163 patients from 183 hospitals were included in the analyses. In the age group of 75 years and older, increasing trends in the number of EHFSs were observed even before the introduction of the FI, while before and after the introduction of the FI, none of the SCs in the monthly number of EHFSs within 2 days, within 1 day, and on the day of admission were statistically significant (incident rate ratio: 1.0043, 95% confidence interval [CI]: [0.9977-1.0111], 1.0068 [0.9987-1.0149], 1.0073 [0.9930-1.0219]). Nor were any of the SCs in in-hospital deaths, perioperative complications, LOS, and IMEs statistically significant. Additionally, there were no statistical differences in the SCs for any of the outcomes between the two age groups.

Conclusion: This study suggested that there was no significant, short-term effect of the FI for surgeries within 48 h after HF on any of the outcomes of interest.

Rationale: The integration of evidence-based practice (EBP) into rehabilitation education programs has been widespread, but little is known about how graduates' EBP competencies evolve over time.

Aims and objectives: To explore how and why the use of EBP by occupational therapists (OTs) and physical therapists (PTs) evolves during the first 3 years of clinical practice.

Method: We used an interpretive description methodology. We conducted semi-structured interviews with OTs and PTs who participated in a minimum of three out of four time points in a previous longitudinal pan-Canadian mixed methods study. Data analysis was guided by Braun and Clarke's approach to thematic analysis.

Results: Seventeen clinicians (13 OTs and 4 PTs) participated in the study. Our analysis identified six overarching themes: (1) evolution of "what EBP is and what it means"; (2) over time, evidence takes a back seat; (3) patients and colleagues have a vital and perennial role in clinical decision making; (4) continuing professional development plays a vital role in EBP; (5) personal attitudes and attributes influence EBP; and (6) organizational factors influence EBP.

Conclusion: Our study highlights the dynamic nature of EBP use among OTs and PTs in the first 3 years of clinical practice, emphasizing the need for contextualized approaches and ongoing support to promote evidence-informed healthcare in rehabilitation.

Rationale: Clinical Practice Guidelines (CPGs) represent evidence-based tools designed to assist healthcare practitioners and patients in decisions in clinical practice. Evidence supports the clinical benefits of adhering to CPGs. However, their successful implementation and adherence in clinical settings often encounter challenges.

Aims and objectives: This systematic review aimed to explore barriers and facilitators influencing adherence to CPGs in Germany.

Method: The protocol of this study was registered in the Open Science Framework (OSF) registry (DOI: 10.17605/OSF. IO/GMFUB). In November 2022 we searched on PubMed and Embase for primary studies employing qualitative, quantitative and mixed-methods approaches that focus on barriers or facilitators to CPGs adherence in the Germany. Two reviewers independently screened articles, extracted data, and evaluated the quality of the studies. The collected data on barriers and facilitators of CPG adherence were systematically categorized and analyzed using the Theoretical Domains Framework (TDF).

Results: A total of 24 studies were included, mainly focusing on adherence to national CPGs. This review introduces a new domain, guideline characteristics, reflecting the need to address barriers and facilitators to CPG development, implementation, dissemination and format, which couldn't be encompassed within the existing 14 domains of TDF framework. Among healthcare professionals, the most frequently reported influencing factors were related to the environmental context and resources (encompassing aspects such as employer support for CPG utilization), the CPG development and dissemination process (including layout, wording, and interactive tools) and beliefs about consequences (such as contradictions with practical experience). Knowledge (knowledge about the content of CPGs, awareness about published CPGs), primarily as a barrier, and reinforcement facilitators (notably financial support), were also frequently reported.

Conclusion: The findings revealed multilevel factors contributing to CPG adherence, with environmental context and resources emerging as the most frequently reported considerations. This systematic review offer holistic insights into the barriers and facilitators of CPG adherence in Germany. The results contribute to a better understanding of the topic and serve as a resource for developing targeted strategies to enhance CPG adherence and implementation within the German healthcare system.

Rationale: Individuals waiting for total-knee-replacement surgery are at risk of developing morbidities and frailty which may affect their postoperative recovery. Multi-modal prehabilitation could mitigate these unintentional effects.

Aims and objectives: To implement and evaluate a specified online multi-modal prehabilitation intervention in patients waiting for total-knee-replacement surgery in a large urban acute hospital trust.

Method: A non-randomised, pre/post analysis implementation pilot with a nested qualitative study was conducted and is reported following the standards for implementation studies (StaRI) guidance. Of 35 listed cases, 12 (34%) were eligible, recruited, and completed an 8-week multi-modal online intervention incorporating 5 modalities (i) cardiovascular exercise, (ii) strength/balance function, (iii) smoking cessation, (iv) opioid use, (v) nutritional intake. Interventions were specified using the Rehabilitation Treatment Specification System, where rehabilitation treatment theory accounts for discrete treatment components. Two participated in an online qualitative interview post-intervention. Process evaluation included intervention fidelity, eligibility/recruitment/retention rates, and clinical outcomes included knee function, frailty, gait velocity, anxiety/depression, and quality of life.

Results: Five participants (42%) completed the intervention and were retained at follow-up. The intervention was delivered online at specified doses, frequency/durations indicative of high respective adherence, quantity, and exposure fidelity. There was significant improvement in median oxford knee score (p = 0.015), gait velocity (p = 0.040) and anxiety (p = 0.023). The interview revealed 5 themes; surgery preconceptions, motivation, acceptability, postoperative experiences, and future recommendations confirming acceptance of the intervention by virtue of adhering to the treatment exposure delivered as planned.

Conclusion: The specified multi-modal prehabilitation was acceptable, implementable, and demonstrated evidence of preliminary efficacy. Further experimental pilot work that represents the spectrum of frailty, obesity, quality of life, and comorbidities associated with total-knee-replacement surgery is indicated.

Objective: A shared decision-making (SDM) model-based intervention programme was implemented for a population at high risk for diabetes to explore its effectiveness in intervening with blood glucose levels in this population.

Methods: One hundred residents were selected according to the principle of voluntary participation and divided into the intervention group (n = 50) and the control group (n = 50) by using multistage cluster sampling. The control group received only brief diabetes knowledge education through a disease brochure issued by the hospital; the intervention group implemented a SDM model based on large classroom and individualised education for 4 months. Univariate analysis and generalised estimating equation fitting model were used to analyse the effect of intervention on blood glucose parameters in the study subjects.

Results: Univariate analysis showed that after 4 months of intervention, fasting blood glucose was lower in the intervention group than in the control group (5.57 ± 0.56 vs. 6.07 ± 0.77, F = 45.721, p < 0.001); glycosylated hemoglobin was lower in the intervention group than in the control group (5.91 ± 0.28 vs. 6.02 ± 0.24, F = 25.998, p < 0.001), decreased by 0.26% in the intervention group and increased by 0.01% in the control group. One-way analysis of variance (ANOVA) showed that fasting blood glucose and glycosylated hemoglobin in the intervention group decreased to different extents from baseline. The generalised estimation equation was fitted with the intervention programme, gender, hypertension, smoking, alcohol consumption, physical activity, age, waist circumference, body mass index, baseline fasting blood glucose, and baseline glycosylated hemoglobin as independent variables, and fasting blood glucose and baseline glycosylated hemoglobin as dependent variables. Results showed that compared with the control group, fasting blood glucose and glycosylated hemoglobin levels were significantly different between the two groups (p < 0.001).

Conclusion: Applying an intervention programme based on SDM model to people at high risk of diabetes can improve patients' adherence to self-management and establish a good lifestyle, thus contributing to their good glycemic control.

Rationale: A barrier to dedicating resources towards patient engagement in primary care quality improvement is the lack of clearly identified outcomes that might result from these initiatives.

Aims and objectives: We sought to identify these potential outcomes at three healthcare levels as defined by the Institute of Medicine: 1) Micro/Direct Care; 2) Meso/Microsystem; and 3) Macro/Clinic/System using a Modified Delphi technique.

Method: Two focus groups of patients and primary care clinician leaders generated a first set of outcomes. These outcomes were then vetted and expanded through three web-based surveys sent to twelve national experts. Experts indicated the level of agreement with prior elicited outcomes and generated potential new outcomes.

Results: Included outcomes achieved at least 80% agreement. The final list of 46 consensus-derived outcomes was categorized across levels. 22 were at the Micro-level, 9 were at the Meso-level, and 15 were at the Macro-level.

Conclusion: Our findings suggest outcomes across all health system levels have the potential for progress when patients are engaged in primary care quality improvement initiatives. Future programs should consider validating and measuring these outcomes as part of their interventions.