Caring for high-need patients.

OBJECTIVE: We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions. METHODS: We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus. RESULTS: The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately. CONCLUSIONS: Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

Quality Indicators for High-Need Patients: a Systematic Review.

BACKGROUND: Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. METHODS: This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. RESULTS: The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. DISCUSSION: We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.

Evidence-Based Quality Improvement: a Scoping Review of the Literature.

BACKGROUND: Quality improvement (QI) initiatives often reflect approaches based on anecdotal evidence, but it is unclear how initiatives can best incorporate scientific literature and methods into the QI process. Review of studies of QI initiatives that aim to systematically incorporate evidence review (termed evidence-based quality improvement (EBQI)) may provide a basis for further methodological development. METHODS: In this scoping review (registration: https://osf.io/hr5bj ) of EBQI, we searched the databases PubMed, CINAHL, and SCOPUS. The review addressed three central questions: How is EBQI defined? How is evidence used to inform evidence-informed QI initiatives? What is the effectiveness of EBQI? RESULTS: We identified 211 publications meeting inclusion criteria. In total, 170 publications explicitly used the term "EBQI." Published definitions emphasized relying on evidence throughout the QI process. We reviewed a subset of 67 evaluations of QI initiatives in primary care, including both studies that used the term "EBQI" with those that described an evidence-based initiative without using EBQI terminology. The most frequently reported EBQI components included use of evidence to identify previously tested effective QI interventions; engaging stakeholders; iterative intervention development; partnering with frontline clinicians; and data-driven evaluation of the QI intervention. Effectiveness estimates were positive but varied in size in ten studies that provided data on patient health outcomes. CONCLUSIONS: EBQI is a promising strategy for integrating relevant prior scientific findings and methods systematically in the QI process, from the initial developmental phase of the IQ initiative through to its evaluation. Future QI researchers and practitioners can use these findings as the basis for further development of QI initiatives.

Eight Priorities for Improving Primary Care Access Management in Healthcare Organizations: Results of a Modified Delphi Stakeholder Panel.

OBJECTIVE: To identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. BACKGROUND: Studies on healthcare access show its importance for ensuring population health. Few studies show how healthcare organizations can improve access. METHODS: We conducted a modified Delphi stakeholder panel anchored by a systematic review. Panelists (N = 20) represented diverse stakeholder groups including patients, providers, policy makers, purchasers, and payers of healthcare services, predominantly from the Veterans Health Administration. A pre-panel survey addressed over 80 aspects of healthcare organization management of access, including defining access management. Panelists discussed survey-based ratings during a 2-day in-person meeting and re-voted afterward. A second panel process focused on each final priority and developed recommendations and suggestions for implementation. RESULTS: The panel achieved consensus on definitions of optimal access and access management on eight urgent and important priorities for guiding access management improvement, and on 1-3 recommendations per priority. Each recommendation is supported by referenced, panel-approved suggestions for implementation. Priorities address two organizational structure targets (interdisciplinary primary care site leadership; clearly identified group practice management structure); four process improvements (patient telephone access management; contingency staffing; nurse management of demand through care coordination; proactive demand management by optimizing provider visit schedules), and two outcomes (quality of patients' experiences of access; provider and staff morale). Recommendations and suggestions for implementation, including literature references, are summarized in a panelist-approved, ready-to-use tool. CONCLUSIONS: A stakeholder panel informed by a pre-panel systematic review identified eight action-oriented priorities for improving access and recommendations for implementing each priority. The resulting tool is suitable for guiding the VA and other integrated healthcare delivery organizations in assessing and initiating improvements in access management, and for supporting continued research.

Sequelae of an Evidence-based Approach to Management for Access to Care in the Veterans Health Administration.

BACKGROUND: Access to health care is a critical concept in the design, delivery, and evaluation of high quality care. Meaningful evaluation of access requires research evidence and the integration of perspectives of patients, providers, and administrators. OBJECTIVE: Because of high-profile access challenges, the Department of Veterans Affairs (VA) invested in research and implemented initiatives to address access management. We describe a 2-year evidence-based approach to improving access in primary care. METHODS: The approach included an Evidence Synthesis Program (ESP) report, a 22-site in-person qualitative evaluation of VA initiatives, and in-person and online stakeholder panel meetings facilitated by the RAND corporation. Subsequent work products were disseminated in a targeted strategy to increase impact on policy and practice. RESULTS: The ESP report summarized existing research evidence in primary care management and an evaluation of ongoing initiatives provided organizational data and novel metrics. The stakeholder panel served as a source of insights and information, as well as a knowledge dissemination vector. Work products included the ESP report, a RAND report, peer-reviewed manuscripts, presentations at key conferences, and training materials for VA Group Practice Managers. Resulting policy and practice implications are discussed. CONCLUSIONS: The commissioning of an evidence report was the beginning of a cascade of work including exploration of unanswered questions, novel research and measurement discoveries, and policy changes and innovation. These results demonstrate what can be achieved in a learning health care system that employs evidence and expertise to address complex issues such as access management.

Recruiting Rural Healthcare Providers Today: a Systematic Review of Training Program Success and Determinants of Geographic Choices.

BACKGROUND: Rural areas have historically struggled with shortages of healthcare providers; however, advanced communication technologies have transformed rural healthcare, and practice in underserved areas has been recognized as a policy priority. This systematic review aims to assess reasons for current providers' geographic choices and the success of training programs aimed at increasing rural provider recruitment. METHODS: This systematic review (PROSPERO: CRD42015025403) searched seven databases for published and gray literature on the current cohort of US rural healthcare practitioners (2005 to March 2017). Two reviewers independently screened citations for inclusion; one reviewer extracted data and assessed risk of bias, with a senior systematic reviewer checking the data; quality of evidence was assessed using the GRADE approach. RESULTS: Of 7276 screened citations, we identified 31 studies exploring reasons for geographic choices and 24 studies documenting the impact of training programs. Growing up in a rural community is a key determinant and is consistently associated with choosing rural practice. Most existing studies assess physicians, and only a few are based on multivariate analyses that take competing and potentially correlated predictors into account. The success rate of placing providers-in-training in rural practice after graduation, on average, is 44% (range 20-84%; N = 31 programs). We did not identify program characteristics that are consistently associated with program success. Data are primarily based on rural tracks for medical residents. DISCUSSION: The review provides insight into the relative importance of demographic characteristics and motivational factors in determining which providers should be targeted to maximize return on recruitment efforts. Existing programs exposing students to rural practice during their training are promising but require further refining. Public policy must include a specific focus on the trajectory of the healthcare workforce and must consider alternative models of healthcare delivery that promote a more diverse, interdisciplinary combination of providers.

Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis.

BACKGROUND: Chronic pain patients increasingly seek treatment through mindfulness meditation. PURPOSE: This study aims to synthesize evidence on efficacy and safety of mindfulness meditation interventions for the treatment of chronic pain in adults. METHOD: We conducted a systematic review on randomized controlled trials (RCTs) with meta-analyses using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the GRADE approach. Outcomes included pain, depression, quality of life, and analgesic use. RESULTS: Thirty-eight RCTs met inclusion criteria; seven reported on safety. We found low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs. Statistically significant effects were also found for depression symptoms and quality of life. CONCLUSIONS: While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.

Guidance for research-practice partnerships (R-PPs) and collaborative research.

PURPOSE: The purpose of this paper is to provide evidence based guidance to researchers and practice personnel about forming and carrying out effective research partnerships. DESIGN/METHODOLOGY/APPROACH: A review of the literature, interviews and discussions with colleagues in both research and practice roles, and a review of the authors' personal experiences as researchers in partnership research. FINDINGS: Partnership research is, in some respects, a distinct "approach" to research, but there are many different versions. An analysis of research publications and of their research experience led the authors to develop a framework for planning and assessing the partnership research process, which includes defining expected outcomes for the partners, their roles, and steps in the research process. PRACTICAL IMPLICATIONS: This review and analysis provides guidance that may reduce commonly-reported misunderstandings and help to plan more successful partnerships and projects. It also identifies future research which is needed to define more precisely the questions and purposes for which partnership research is most appropriate, and methods and designs for specific types of partnership research. ORIGINALITY/VALUE: As more research moves towards increased participation of practitioners and patients in the research process, more precise and differentiated understanding of the different partnership approaches is required, and when each is most suitable. This article describes research approaches that have the potential to reduce "the research-practice gap". It gives evidence- and experience-based guidance for choosing and establishing a partnership research process, so as to improve partnership relationship-building and more actionable research.

Treatments for ADHD in Children and Adolescents: A Systematic Review.

CONTEXT: Effective treatment of attention-deficit/hyperactivity disorder (ADHD) is essential to improving youth outcomes. OBJECTIVES: This systematic review provides an overview of the available treatment options. DATA SOURCES: We identified controlled treatment evaluations in 12 databases published from 1980 to June 2023; treatments were not restricted by intervention content. STUDY SELECTION: Studies in children and adolescents with clinically diagnosed ADHD, reporting patient health and psychosocial outcomes, were eligible. Publications were screened by trained reviewers, supported by machine learning. DATA EXTRACTION: Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Data were pooled using random-effects models. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards. RESULTS: In total, 312 studies reported in 540 publications were included. We grouped evidence for medication, psychosocial interventions, parent support, nutrition and supplements, neurofeedback, neurostimulation, physical exercise, complementary medicine, school interventions, and provider approaches. Several treatments improved ADHD symptoms. Medications had the strongest evidence base for improving outcomes, including disruptive behaviors and broadband measures, but were associated with adverse events. LIMITATIONS: We found limited evidence of studies comparing alternative treatments directly and indirect analyses identified few systematic differences across stimulants and nonstimulants. Identified combination of medication with youth-directed psychosocial interventions did not systematically produce better results than monotherapy, though few combinations have been evaluated. CONCLUSIONS: A growing number of treatments are available that improve ADHD symptoms and other outcomes, in particular for school-aged youth. Medication therapies remain important treatment options but are associated with adverse events.

Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination.

A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.

Programs for Care System Transitions in Mental Health: A Systematic Review.

Although transitions between health care systems are common when patients move between jobs or insurers, they are especially difficult to navigate when patients with mental health conditions leave an integrated system, such as the Military Health System (MHS). The authors synthesize evidence from studies of interventions that facilitate transitions between mental health care systems, such as the transition from the MHS to the Veterans Health Administration (VHA). The authors searched multiple research databases, reference-mined bibliographies of existing reviews, and consulted with experts to identify existing evaluations of transition support interventions. Key informants helped identify pertinent populations of interest who are transitioning between health care systems. Seventeen studies evaluating different approaches met inclusion criteria. Studies reported on different outcomes, and few could be combined in aggregated analyses. Analyses showed that care transition interventions can increase outpatient mental health service use, but the overall body of evidence is limited.

Combat and Operational Stress Control Interventions and PTSD: A Systematic Review and Meta-Analysis.

INTRODUCTION: Military personnel must prepare for and respond to life-threatening crises on a daily basis. This lifestyle places stress on personnel, and particularly so on deployed service members who are isolated from support systems and other resources. As part of a larger systematic review on the acceptability, efficacy, and comparative effectiveness of interventions designed to prevent, identify, and manage stress reactions, we assessed posttraumatic stress disorder (PTSD) outcomes. MATERIALS AND METHODS: We searched the electronic databases PsycINFO, PubMed, PTSDPubs, the Defense Technical Information Center, and Cochrane Central, as well as bibliographies of existing systematic reviews, to identify English-language studies evaluating the efficacy or comparative effectiveness of stress control interventions published since 1990. Controlled trials and cohort comparisons of interventions with military, law enforcement, and first responders were included. Two independent reviewers screened literature using predetermined eligibility criteria. Researchers individually abstracted study-level information and outcome data and assessed the risk of bias of included studies; data were reviewed for accuracy by the project leader. Changes in PTSD symptom scores from baseline to post-intervention were converted to standardized mean differences for comparison across studies. Risk ratios were calculated for PTSD case rates post-deployment. When several studies that compared an intervention group with a similar control/comparator reported the same outcome category and measure type, we conducted meta-analysis. We conducted meta-regression by adding a categorical variable, representing setting (i.e., in theater) or population (military vs. law enforcement or first responders) to the meta-analysis model to assess whether this variable was associated with the outcome across studies. The quality of the body of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers study limitations (risk of bias), directness, consistency, precision, and publication bias. RESULTS: Sixteen controlled trials and 13 cohort comparisons reporting PTSD outcomes met inclusion criteria. Eight controlled trials and two cohort studies had high risk of bias, primarily due to poor, differential, or unknown response rate at follow-up. Twenty-four of the 29 studies included military personnel. Interventions included Acceptance-based Skills training, Attention Bias Modification training, stress inoculation with biofeedback, Critical Incident Stress Debriefing, group psychological debriefing, Eye Movement Desensitization and Reprocessing for sub-clinical stress, embedding mental health providers in theater, Third Location Decompression, reintegration programs, and a 3-week post-deployment residential program for psychological resource strengthening.Meta-analyses of studies comparing a group that received a stress control intervention to a group that did not receive an intervention found no significant difference in reduction in PTSD symptom scores (moderate QoE) or PTSD case rate post-deployment (low QoE). A meta-analysis of studies comparing a specific stress control intervention to an active comparator (usually standard stress management education) found no significant effect on PTSD symptom scores (moderate QoE). CONCLUSION: Although combat and operational stress control (COSC) interventions may play a valuable role in decreasing stress, decreasing absenteeism, and enabling return to duty, a systematic review of 29 studies that included a control/comparison group found little evidence that COSC is effective in preventing PTSD or decreasing PTSD symptom scores in military personnel.

The integration of primary care and childhood cancer survivorship care: a scoping review.

PURPOSE: This scoping review describes existing care models that integrate primary care and childhood cancer survivorship care, examines the effectiveness of these models, and characterizes barriers and facilitators to their integration. METHODS: A systematic search (PubMed®, CINAHL®, Embase®) was conducted to identify citations which were evaluated against inclusion criteria using the PICOTTS framework. The PRISMA-ScR extension for scoping reviews was used to report review findings (protocol https://osf.io/92xbg ). RESULTS: Twenty-three studies were included. Three care models integrating primary care and childhood cancer survivorship care were identified: consultative shared care in a primary care setting (N = 3); longitudinal shared care (N = 2); and PCP-led care employing a survivorship care plan (N = 5). While many described risk-adapted care, few used risk stratification approaches to inform care. Measures of model effectiveness varied, with discrepant findings regarding late effects detection in PCP-led approaches. The most frequently cited barriers and facilitators reflected provider- and system-level factors (PCP knowledge/experience identified as greatest barrier (N = 11); clinical information from oncologist identified as greatest facilitator (N = 9)). CONCLUSIONS: Identified models depended on PCP knowledge and healthcare system coordination, and studies suggested the need for strong oncologic involvement in follow-up care. Improved training for PCPs and the coordinated transfer of clinical information could facilitate their involvement in such care. Overall, standardized measures of effectiveness are needed to deliver optimal childhood cancer survivorship care. IMPLICATIONS FOR CANCER SURVIVORS: The literature revealed three care models defined by SCP use, provider involvement, and continuity of care, with several studies recommending oncologic involvement in follow-up care for high-risk survivors.

Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions.

BACKGROUND: A systematic review of the literature on nurse-focused interventions conducted in the hospital setting informs the evidence base for implementation of pressure ulcer (PU) prevention programs. Despite the availability of published guidelines, there is little evidence about which interventions can be successfully integrated into routine care through quality improvement (QI). The two previous literature syntheses on PU prevention have included articles from multiple settings but have not focused specifically on QI. METHODS: A search of six electronic databases for publications from January 1990 to September 2009 was conducted. Trial registries and bibliographies of retrieved studies and reviews, and Internet sites of funding agencies were also searched. Using standardized forms, two independent reviewers screened publications for eligibility into the sample; data were abstracted and study quality was assessed for those that passed screening. FINDINGS: Thirty-nine studies met the inclusion criteria. Most of them used a before-and-after study design in a single site. Intervention strategies included PU-specific changes in combination with educational and/or QI strategies. Most studies reported patient outcome measures, while fewer reported nursing process of care measures. For nearly all the studies, the authors concluded that the intervention had a positive effect. The pooled risk difference for developing PUs was -.07 (95% confidence interval [CI]: -0.0976, -0.0418) comparing the pre- and postintervention status. CONCLUSION: Future research can build the evidence base for implementation through an increased emphasis on understanding the mechanisms by which improved outcomes are achieved and describing the conditions under which specific intervention strategies are likely to succeed or fail.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol.

INTRODUCTION: There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive. METHODS AND ANALYSIS: Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma. PROSPERO REGISTRATION NUMBER: CRD42021249348.

Evidence map of ductal carcinoma in situ management options.

OBJECTIVE: Ductal carcinoma in situ (DCIS) has the potential to progress to invasive carcinoma. The optimal management of DCIS and methods for individualizing treatment of DCIS are still being determined. This evidence map depicts the robustness and topical span of research on DCIS management choice on patient-centered and clinical outcomes. METHODS: We searched PubMed, EMBASE, PsycINFO, PubMed Health, PROSPERO, and clinical practice guideline sites to identify systematic reviews of DCIS management options and consulted with topic experts. A bubble plot visualizes the literature volume and research content for patient-centered outcomes. An online decision tree facilitates discussions with patients and guides through the available evidence. RESULTS: In total, 40 systematic reviews met inclusion criteria. The research syntheses addressed DCIS management options, including the role of magnetic resonance imaging, axillary surgery/sentinel lymph node biopsy, and excisional biopsy. The map shows existing evidence for mutually exclusive treatment options including active surveillance, breast-conserving surgery, nipple sparing mastectomy, and simple mastectomy. Research findings for intraoperative radiation, adjuvant radiation therapy, adjuvant hormone therapy, hypofractionation radiotherapy, accelerated partial breast irradiation, radiation therapy plus boost, and combined radiation and hormone therapy, as well as for breast reconstruction after mastectomy and surveillance mammography postsurgery are also displayed. The evidence map highlights a scarcity of robust evidence on patient-centered outcomes. CONCLUSIONS: The evidence map provides an overview of DCIS research showing the range of management options and remaining decisional dilemmas that follow a diagnosis of DCIS. It maps the evidence in accessible tools to guide practice and future research. : Video Summary:http://links.lww.com/MENO/A448.

Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression.

BACKGROUND: Depression is a common mental health disorder for which clinical practice guidelines have been developed. Prior systematic reviews have identified complex organizational interventions, such as collaborative care, as effective for guideline implementation; yet, many healthcare delivery organizations are interested in less resource-intensive methods to increase provider adherence to guidelines and guideline-concordant practices. The objective of this systematic review was to assess the effectiveness of healthcare provider interventions that aim to increase adherence to evidence-based treatment of depression in routine clinical practice. METHODS: We searched five databases through August 2017 using a comprehensive search strategy to identify English-language randomized controlled trials (RCTs) in the quality improvement, implementation science, and behavior change literature that evaluated outpatient provider interventions, in the absence of practice redesign efforts, to increase adherence to treatment guidelines or guideline-concordant practices for depression. We used meta-analysis to summarize odds ratios, standardized mean differences, and incidence rate ratios, and assessed quality of evidence (QoE) using the GRADE approach. RESULTS: Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline-concordant practices met inclusion criteria. Studies evaluated diverse provider interventions, including distributing guidelines to providers, education/training such as academic detailing, and combinations of education with other components such as targeting implementation barriers. Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies. There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes. We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies. Effects on patients' health in these RCTs were inconsistent across studies and outcomes. CONCLUSIONS: Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines. Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research. Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence-based treatment for depression. TRIAL REGISTRATION: PROSPERO record CRD42017060460 on 3/29/17.

A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition.

CONTEXT: Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers. OBJECTIVES: The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. METHODS: Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel. RESULTS: We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews). CONCLUSION: A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.

Mindfulness-based Relapse Prevention for Substance Use Disorders: A Systematic Review and Meta-analysis.

OBJECTIVES: Substance use disorder (SUD) is a prevalent health issue with serious personal and societal consequences. This review aims to estimate the effects and safety of Mindfulness-based Relapse Prevention (MBRP) for SUDs. METHODS: We searched electronic databases for randomized controlled trials evaluating MBRP for adult patients diagnosed with SUDs. Two reviewers independently assessed citations, extracted trial data, and assessed risks of bias. We conducted random-effects meta-analyses and assessed quality of the body of evidence (QoE) using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: We identified 9 randomized controlled trials comprising 901 participants. We did not detect statistically significant differences between MBRP and comparators on relapse (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.46-1.13, low QoE), frequency of use (standardized mean difference [SMD] 0.02, 95% CI -0.40 to 0.44, low QoE), treatment dropout (OR 0.81, 95% CI 0.40 to 1.62, very low QoE), depressive symptoms (SMD -0.09, 95% CI -0.39 to 0.21, low QoE), anxiety symptoms (SMD -0.32, 95% CI -1.16 to 0.52, very low QoE), and mindfulness (SMD -0.28, 95% CI -0.72 to 0.16, very low QoE). We identified significant differences in favor of MBRP on withdrawal/craving symptoms (SMD -0.13, 95% CI -0.19 to -0.08, I = 0%, low QoE) and negative consequences of substance use (SMD -0.23, 95% CI -0.39 to -0.07, I = 0%, low QoE). We found negligible evidence of adverse events. CONCLUSIONS: We have limited confidence in estimates suggesting MBRP yields small effects on withdrawal/craving and negative consequences versus comparator interventions. We did not detect differences for any other outcome. Future trials should aim to minimize participant attrition to improve confidence in effect estimates.

Efficacy of mindfulness meditation for smoking cessation: A systematic review and meta-analysis.

BACKGROUND: Smokers increasingly seek alternative interventions to assist in cessation or reduction efforts. Mindfulness meditation, which facilitates detached observation and paying attention to the present moment with openness, curiosity, and acceptance, has recently been studied as a smoking cessation intervention. AIMS: This review synthesizes randomized controlled trials (RCTs) of mindfulness meditation (MM) interventions for smoking cessation. METHODS: Five electronic databases were searched from inception to October 2016 to identify English-language RCTs evaluating the efficacy and safety of MM interventions for smoking cessation, reduction, or a decrease in nicotine cravings. Two independent reviewers screened literature using predetermined eligibility criteria, abstracted study-level information, and assessed the quality of included studies. Meta-analyses used the Hartung-Knapp-Sidik-Jonkman method for random-effects models. The quality of evidence was assessed using the GRADE approach. FINDINGS: Ten RCTs of MM interventions for tobacco use met inclusion criteria. Intervention duration, intensity, and comparison conditions varied considerably. Studies used diverse comparators such as the American Lung Association's Freedom from Smoking (FFS) program, quitline counseling, interactive learning, or treatment as usual (TAU). Only one RCT was rated as good quality and reported power calculations indicating sufficient statistical power. Publication bias was detected. Overall, mindfulness meditation did not have significant effects on abstinence or cigarettes per day, relative to comparator groups. The small number of studies and heterogeneity in interventions, comparators, and outcomes precluded detecting systematic differences between adjunctive and monotherapy interventions. No serious adverse events were reported. CONCLUSIONS: MM did not differ significantly from comparator interventions in their effects on tobacco use. Low-quality evidence, variability in study design among the small number of existing studies, and publication bias suggest that additional, high-quality adequately powered RCTs should be conducted.