Juan I. Baeza

Effective implementation of research into practice: an overview of systematic reviews of the health literature.

BackgroundThe gap between research findings and clinical practice is well documented and a range of interventions has been developed to increase the implementation of research into clinical practice.FindingsA review of systematic reviews of the effectiveness of interventions designed to increase the use of research in clinical practice. A search for relevant systematic reviews was conducted of Medline and the Cochrane Database of Reviews 1998-2009. 13 systematic reviews containing 313 primary studies were included. Four strategy types are identified: audit and feedback; computerised decision support; opinion leaders; and multifaceted interventions. Nine of the reviews reported on multifaceted interventions. This review highlights the small effects of single interventions such as audit and feedback, computerised decision support and opinion leaders. Systematic reviews of multifaceted interventions claim an improvement in effectiveness over single interventions, with effect sizes ranging from small to moderate. This review found that a number of published systematic reviews fail to state whether the recommended practice change is based on the best available research evidence.ConclusionsThis overview of systematic reviews updates the body of knowledge relating to the effectiveness of key mechanisms for improving clinical practice and service development. Multifaceted interventions are more likely to improve practice than single interventions such as audit and feedback. This review identified a small literature focusing explicitly on getting research evidence into clinical practice. It emphasizes the importance of ensuring that primary studies and systematic reviews are precise about the extent to which the reported interventions focus on changing practice based on research evidence (as opposed to other information codified in guidelines and education materials).

Partnerships in primary care in Australia: network structure, dynamics and sustainability

Partnerships represent a prescriptive form of network governance, based on the idea of cooperation. This article has four aims. The first is to describe why network governance and partnerships are important now, and what one particular example - Primary Care Partnerships - is addressing. The second is to analyse the network structure of two of these partnerships, and the third is to examine network dynamics. The fourth aim is to explore relationships and sustainability over the longer term. Two government-funded and steered partnerships, which were established to increase coordination between primary care services in Victoria, Australia, were examined. Annual interviews at three points in time between 2002 and 2005 were used to explore relationships between organizations within these two partnerships. The structure of two different communication networks, based on contacts for work and contacts for strategic information, were examined using social network analysis. Tracing network structures over time highlighted partnership dynamics. The network structures changed over the three years of the study, but an important constant was the continuing centrality of the independent staff employed to manage the partnerships. Over the longer term, it seems to be more important to fund independent partnership staff, rather than people who connect partnerships to the funding agency. If partnerships are seen as valuable in improving service coordination and health outcomes, then long term rather than just start-up funding support is required.

Indigenous health organizations in Australia: connections and capacity.

The health of Aboriginal people is significantly worse than that of the rest of the Australian population. Aboriginal community-controlled health organizations live with uncertainty in terms of funding, and the amount of money spent on indigenous people through mainstream health services is less than that spent on the non-indigenous population, especially when the different needs of these two groups are taken into account. The Aboriginal population is small and widely dispersed, causing problems for policy and funding. This article provides an analysis of the network of health organizations in Victoria, with a specific focus on indigenous health, and analyzes the connections between mainstream and indigenous-specific health services. The research approach involved semi-structured interviews with informants from a range of health organizations within the state. This research illustrates the importance of Aboriginal community-controlled health organizations to the indigenous community. There is evidence that connections between the indigenous and mainstream health systems need to be further developed and strengthened to provide the indigenous population with a high-quality, culturally sensitive, and comprehensive health service.

The new health promotion arrangements in general medical practice in England: Results from a national evaluation

The new health promotion arrangements were introduced in October 1996. This study, commissioned by the Department of Health, aimed to assess the extent of health promotion activity under the new arrangements, and to explore views about their implementation. The study was conducted in two parts. The first stage consisted of a telephone survey with a nominated person from each health authority in England. The second phase, reported here, consisted of semi-structured face-to- face interviews in six health authority case study sites. Sixty-nine interviews were conducted with a range of key health promotion informants. The most common focus of health promotion activity related to coronary heart disease and stroke with less emphasis on other Health of the Nation target areas. Monitoring of health promotion was generally low-key and informal which led to concerns about effectiveness and accountability. There was little evidence of evaluation of health promotion activities by practices, although most routinely carried out audit. The regulatory role of HPCs appeared to be lessening, and they were being overshadowed by HimPs and PCGs. These findings raise issues which will have important implications for the future development of health promotion services.

The use of patient feedback by hospital boards of directors: a qualitative study of two NHS hospitals in England

Background Although previous research suggests that different kinds of patient feedback are used in different ways to help improve the quality of hospital care, there have been no studies of the ways in which hospital boards of directors use feedback for this purpose. Objectives To examine whether and how boards of directors of hospitals use feedback from patients to formulate strategy and to assure and improve the quality of care. Methods We undertook an in-depth qualitative study in two acute hospital National Health Service foundation trusts in England, purposively selected as contrasting examples of the collection of different kinds of patient feedback. We collected and analysed data from interviews with directors and other managers, from observation of board meetings, and from board papers and other documents. Results The two boards used in-depth qualitative feedback and quantitative feedback from surveys in different ways to help develop strategies, set targets for quality improvement and design specific quality improvement initiatives; but both boards made less subsequent use of any kinds of feedback to monitor their strategies or explicitly to assure the quality of services. Discussion and conclusions We have identified limitations in the uses of patient feedback by hospital boards that suggest that boards should review their current practice to ensure that they use the different kinds of patient feedback that are available to them more effectively to improve, monitor and assure the quality of care.

The importance of normative integration in stroke services: Case study evidence from Sweden and England:

Summary Objectives: A number of evidence-based interventions are now available for stroke patients. Good-quality stroke care involves a range of health professionals located across ambulance, hospital, community and primary care services. This study examined the perspectives of health-care workers involved in stroke care in Sweden and England on the integration challenges stroke care presents. Methods: Four qualitative case studies were carried out in Sweden and England, including 95 semistructured interviews with clinicians and managers associated with four different hospitals providing specialized stroke services. Findings: High levels of organizational, functional, service and clinical integration among clinicians that deliver emergency and acute stroke care were identified. This is frequently lacking among professionals delivering postacute care. These findings are linked to the prevalence or lack of normative and systemic integration in each respective stage of care. Conclusions: Emphasis on the need to treat stroke as an emergency condition in both countries has created a context in which normative and systemic integration often occurs among clinicians that deliver emergency and acute stroke care, aiding the development of organizational, functional, service and clinical integration across the case study sites. In contrast, integration between hospital and community (rehabilitation and general practice) care is frequently less successful.

Does the 'diffusion of innovations' model enrich understanding of research use? Case studies of the implementation of thrombolysis services for stroke.

Objective To test whether the model of ‘diffusion of innovations’ enriches understanding of the implementation of evidence-based thrombolysis services for stroke patients. Methods Four case studies of the implementation of evidence on thrombolysis in stroke services in England and Sweden. Semistructured interviews with 95 staff including doctors, nurses and managers working in stroke units, emergency medicine, radiology, the ambulance service, community rehabilitation services and commissioners. Results The implementation of thrombolysis in acute stroke management benefited from a critical mass of the factors featured in the model including: the support of national and local opinion leaders; a strong evidence base and financial incentives. However, while the model provided a starting point as an organizational framework for mapping the critical factors influencing implementation, to understand properly the process of implementation and the importance of the different factors identified, more detailed analyses of context and, in particular, of the human and social dimensions of change was needed. Conclusions While recognising the usefulness of the model of diffusion of innovations in mapping the processes by which diffusion occurs, the use of methods that lend themselves to in-depth analysis, such as ethnography and the application of relevant bodies of social theory, are needed.

Methods of Implementation of Evidence-Based Stroke Care in Europe European Implementation Score Collaboration

Background and Purpose— Differences in stroke care and outcomes reported in Europe may reflect different degrees of implementation of evidence-based interventions. We evaluated strategies for implementing research evidence into stroke care in 10 European countries. Methods— A questionnaire was developed and administered through face-to-face interviews with key informants. Implementation strategies were investigated considering 3 levels (macro, meso, and micro, eg, policy, organization, patients/professionals) identified by the framing analysis, and different settings (primary, hospital, and specialist) of stroke care. Similarities and differences among countries were evaluated using the categorical principal components analysis. Results— Implementation methods reported by ≥7 countries included nonmandatory policies, public financial incentives, continuing professional education, distribution of educational material, educational meetings and campaigns, guidelines, opinion leaders’, and stroke patients associations’ activities. Audits were present in 6 countries at national level; national and regional regulations in 4 countries. Private financial incentives, reminders, and educational outreach visits were reported only in 2 countries. At national level, the first principal component of categorical principal components analysis separated England, France, Scotland, and Sweden, all with positive object scores, from the other countries. Belgium and Lithuania obtained the lowest scores. At regional level, England, France, Germany, Italy, and Sweden had positive scores in the first principal component, whereas Belgium, Lithuania, Poland, and Scotland showed negative scores. Spain was in an intermediate position. Conclusions— We developed a novel method to assess different domains of implementation in stroke care. Clear variations were observed among European countries. The new tool may be used elsewhere for future contributions.

Temporal Changes in the Quality of Acute Stroke Care in Five National Audits across Europe.

Background. Data on potential variations in delivery of appropriate stroke care over time are scarce. We investigated temporal changes in the quality of acute hospital stroke care across five national audits in Europe over a period of six years. Methods. Data were derived from national stroke audits in Germany, Poland, Scotland, Sweden, and England/Wales/Northern Ireland participating within the European Implementation Score (EIS) collaboration. Temporal changes in predefined quality indicators with comparable information between the audits were investigated. Multivariable logistic regression analyses were performed to estimate adherence to quality indicators over time. Results. Between 2004 and 2009, individual data from 542,112 patients treated in 538 centers participating continuously over the study period were included. In most audits, the proportions of patients who were treated on a SU, were screened for dysphagia, and received thrombolytic treatment increased over time and ranged from 2-fold to almost 4-fold increase in patients receiving thrombolytic therapy in 2009 compared to 2004. Conclusions. A general trend towards a better quality of stroke care defined by standardized quality indicators was observed over time. The association between introducing a specific measure and higher adherence over time might indicate that monitoring of stroke care performance contributes to improving quality of care.

Improving sexual health services in the city: can the NHS learn from clients and the service industry.

Objective  Genitourinary service providers are struggling to meet patient demand and have introduced changes in access structure to cope. In this study, we explored the perspectives of clients and providers upon the different models of access introduced and whether these maintained service quality using the SERQUAL model.