Allopurinol and blood pressure variability following ischemic stroke and transient ischemic attack: a secondary analysis of XILO-FIST.

Blood Pressure Variability (BPV) is associated with cardiovascular risk and serum uric acid level. We investigated whether BPV was lowered by allopurinol and whether it was related to neuroimaging markers of cerebral small vessel disease (CSVD) and cognition. We used data from a randomised, double-blind, placebo-controlled trial of two years allopurinol treatment after recent ischemic stroke or transient ischemic attack. Visit-to-visit BPV was assessed using brachial blood pressure (BP) recordings. Short-term BPV was assessed using ambulatory BP monitoring (ABPM) performed at 4 weeks and 2 years. Brain MRI was performed at baseline and 2 years. BPV measures were compared between the allopurinol and placebo groups, and with CSVD and cognition. 409 participants (205 allopurinol; 204 placebo) were included in the visit-to-visit BPV analyses. There were no significant differences found between placebo and allopurinol groups for any measure of visit-to-visit BPV. 196 participants were included in analyses of short-term BPV at week 4. Two measures were reduced by allopurinol: the standard deviation (SD) of systolic BP (by 1.30 mmHg (95% confidence interval (CI) 0.18-2.42, p = 0.023)); and the average real variability (ARV) of systolic BP (by 1.31 mmHg (95% CI 0.31-2.32, p = 0.011)). There were no differences in other measures at week 4 or in any measure at 2 years, and BPV was not associated with CSVD or cognition. Allopurinol treatment did not affect visit-to-visit BPV in people with recent ischemic stroke or TIA. Two BPV measures were reduced at week 4 by allopurinol but not at 2 years.

Preventing hospital falls: feasibility of care workforce redesign to optimise patient falls education.

OBJECTIVE: To examine the feasibility of using allied health assistants to deliver patient falls prevention education within 48 h after hospital admission. DESIGN AND SETTING: Feasibility study with hospital patients randomly allocated to usual care or usual care plus additional patient falls prevention education delivered by supervised allied health assistants using an evidence-based scripted conversation and educational pamphlet. PARTICIPANTS: (i) allied health assistants and (ii) patients admitted to participating hospital wards over a 20-week period. OUTCOMES: (i) feasibility of allied health assistant delivery of patient education; (ii) hospital falls per 1,000 bed days; (iii) injurious falls; (iv) number of falls requiring transfer to an acute medical facility. RESULTS: 541 patients participated (median age 81 years); 270 control group and 271 experimental group. Allied health assistants (n = 12) delivered scripted education sessions to 254 patients in the experimental group, 97% within 24 h after admission. There were 32 falls in the control group and 22 in the experimental group. The falls rate was 8.07 falls per 1,000 bed days in the control group and 5.69 falls per 1,000 bed days for the experimental group (incidence rate ratio = 0.66 (95% CI 0.32, 1.36; P = 0.26)). There were 2.02 injurious falls per 1,000 bed days for the control group and 1.03 for the experimental group. Nine falls (7 control, 2 experimental) required transfer to an acute facility. No adverse events were attributable to the experimental group intervention. CONCLUSIONS: It is feasible and of benefit to supplement usual care with patient education delivered by allied health assistants.

Virtual reality simulation for nursing education: effectiveness and feasibility.

Virtual Reality simulation (VRS) is an innovative and emerging technology that has the potential to offer increased numbers of pre-registration students authentic learning experiences compared to traditional simulation- based education (SBE) with simulated participants. The aim was to evaluate learner outcomes of SBE compared to 4 fully immersive VRS scenarios, for vocational and higher education nursing students at a training and further education institute in Melbourne, Australia. A mixed methods quasi-experimental design study was conducted over two semesters from 2019 to 2020. Participants were 675 pre-registration nursing students. The intervention group (VRS n = 393) received 4 three-dimensional, immersive VRS modules. The control group (SBE n = 282) received 4 face-to-face large group immersive simulations. In the VRS group 95% of students actively participated, compared to SBE (on average 15%). Knowledge test scores were initially significantly greater (p < 0.01) for VRS versus SBE students, but not maintained post clinical placement. Intervention students found VRS to be realistic and prepared them for clinical practice. Some technical difficulties were identified with VRS. VRS was found to be more cost effective than SBE. VRS fostered critical thinking and provided an efficient and sustainable platform for learning about complex clinical situations.

Instruments evaluating the quality of the clinical learning environment in nursing education: An updated systematic review.

OBJECTIVES: The clinical learning environment offers meaningful learning opportunities for nursing students to apply theoretical knowledge to practice on actual or simulated patients. A previous systematic review assessed the quality of several instruments that evaluated the quality of clinical learning environments. This updated systematic review aimed to identify: any additional instruments that have been researched in the last 5 years, ii) the psychometric properties of available instruments and iii) the estimated comparable psychometric properties of the available instruments. DATA SOURCES: Medline, CINAHL and Cochrane databases REVIEW METHODS: Databases were searched from January 2016 to January 2023. Studies were included if they: a) validated instruments evaluating the experience and quality of clinical learning environments; b) assessed the pre-licensure nursing student experience; c) were published in English; and d) were published after April 2016. Two independent reviewers conducted title and abstract screening, full text screening, data extraction and methodological quality assessment. Any disagreements were resolved by consensus. A summary of the findings was tabulated using the same format as the initial review. RESULTS: An additional 18 studies were found, which used seven different clinical learning environment evaluation instruments. Internal consistency and structural validity were the most frequently reported psychometric properties. In almost all studies, methodology for these properties were of sufficient quality according to the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) tool evaluation. Other properties were inconsistently reported, with differing qualities in the methodology. Clinical Learning Environment, Supervision and Nurse Teacher (CLES + T) remains the most translated and validated instrument across several countries. CONCLUSIONS: Instruments developed and validated using a systematic, transparent and high-quality methodology assist in accurately assessing the skills, attitudes and decision-making abilities of the preregistration level nursing student. These tools can be used in clinical placement accreditation and quality improvement of nursing education. The methodology for evaluation of the psychometric properties of instruments should be clearly described.

Investigating the Effects of Intraprofessional Learning in Nursing Education: Protocol for a Longitudinal Study.

Interprofessional learning (IPL), where nursing students learn how to work with multiple health professionals in their future practice to deliver the highest quality of care, has become an essential feature of undergraduate nursing programs. Intraprofessional learning (IaPL) is where individuals of two or more disciplines within the same profession collaborate; however, there is a dearth of literature investigating its effects in nursing education. The aim of this study is to investigate the impact of IaPL on the development of nursing students' knowledge, skills, and attitudes for collaborative practice. The study will utilize a mixed methods approach with surveys conducted at six time points across two years of two nursing programs and focus groups at the end of the program. Participants will be recruited from the Diploma and Bachelor of Nursing programs at an Australian Training and Further Education institute. Four specific IaPL educational experiences incorporating simulation will be developed on aged care, mental health, complex care and acute care. The study will provide nursing students with multiple opportunities to develop the necessary capabilities for collaborative practice. It will longitudinally evaluate nursing students' attitudes towards IaPL and examine whether IaPL motivates Diploma of Nursing students to pathway into a Bachelor of Nursing degree. The study will also investigate awareness amongst nursing students of the scope of practice, roles and responsibilities of the nursing team.

Xanthine oxidase inhibition and white matter hyperintensity progression following ischaemic stroke and transient ischaemic attack (XILO-FIST): a multicentre, double-blinded, randomised, placebo-controlled trial.

Background: People who experience an ischaemic stroke are at risk of recurrent vascular events, progression of cerebrovascular disease, and cognitive decline. We assessed whether allopurinol, a xanthine oxidase inhibitor, reduced white matter hyperintensity (WMH) progression and blood pressure (BP) following ischaemic stroke or transient ischaemic attack (TIA). Methods: In this multicentre, prospective, randomised, double-blinded, placebo-controlled trial conducted in 22 stroke units in the United Kingdom, we randomly assigned participants within 30-days of ischaemic stroke or TIA to receive oral allopurinol 300 mg twice daily or placebo for 104 weeks. All participants had brain MRI performed at baseline and week 104 and ambulatory blood pressure monitoring at baseline, week 4 and week 104. The primary outcome was the WMH Rotterdam Progression Score (RPS) at week 104. Analyses were by intention to treat. Participants who received at least one dose of allopurinol or placebo were included in the safety analysis. This trial is registered with ClinicalTrials.gov, NCT02122718. Findings: Between 25th May 2015 and the 29th November 2018, 464 participants were enrolled (232 per group). A total of 372 (189 with placebo and 183 with allopurinol) attended for week 104 MRI and were included in analysis of the primary outcome. The RPS at week 104 was 1.3 (SD 1.8) with allopurinol and 1.5 (SD 1.9) with placebo (between group difference -0.17, 95% CI -0.52 to 0.17, p = 0.33). Serious adverse events were reported in 73 (32%) participants with allopurinol and in 64 (28%) with placebo. There was one potentially treatment related death in the allopurinol group. Interpretation: Allopurinol use did not reduce WMH progression in people with recent ischaemic stroke or TIA and is unlikely to reduce the risk of stroke in unselected people. Funding: The British Heart Foundation and the UK Stroke Association.

An integrated practical placement programme for students with disability: A pilot study.

Supported work internship programmes for young adults with disability are an evidence-based model, leading to greater employment outcomes. This mixed methods pilot study evaluated the experiences of students, supervisors and a project coordinator, who participated in an Integrated Practical Placement (IPP) programme for students with disability in Australia. Intervention students (n = 10) completed 3, 9-week rotations, and accessed personal placement support and employment coaches. Comparison students (n = 38) completed 3, 2-week placements without additional support. Intervention students perceived significantly greater initial changes in work skills (p < 0.01) and work readiness (p < 0.05). Intervention students reported development of communication and self-organisational skills and stressed the value of staff support. Post programme 70% of intervention students gained employment, compared with 15.4% of comparison students. The findings suggest an evidence-based supported employment programme emphasising personalised assessment and training, could provide individuals with disability the required skills to enable successful employment.

Interprofessional education to implement patient falls education in hospitals: Lessons learned.

AIM: The aim of this study was to design, deliver and evaluate an interprofessional education programme for healthcare professionals on how to implement a modified version of the safe recovery programme to prevent falls in hospitalized patients. DESIGN: Mixed methods design incorporating pre- and post education surveys and individual semi-structured interviews. METHODS: Thirty-four health professional participants attended a 1-h face-to-face or Zoom® interprofessional education session to learn how to deliver an evidence-based patient falls prevention education strategy, the modified Safe Recovery Programme. RESULTS: A 1-hour education session was insufficient to build full confidence to deliver the Safe Recovery Programme. There was no statistically significant change in participant views on interprofessional collaboration. Participants recommended prior consultation and preparation before delivery of IPE, with additional opportunities for discussion and feedback during implementation with patients. The findings highlight the importance of interprofessional education for evidence-based interventions in hospitals. Health professionals value education that is timely, interactive, realistic and engaging.

Implementing Patient Falls Education in Hospitals: A Mixed-Methods Trial.

Patient education is key to preventing hospital falls yet is inconsistently implemented by health professionals. A mixed methods study was conducted involving a ward-based evaluation of patients receiving education from health professionals using a scripted conversation guide with a falls prevention brochure, followed by semi-structured qualitative interviews with a purposive sample of health professionals involved in delivering the intervention. Over five weeks, 37 patients consented to surveys (intervention n = 27; control n = 10). The quantitative evaluation showed that falls prevention education was not systematically implemented in the trial ward. Seven individual interviews were conducted with health professionals to understand the reasons why implementation failed. Perceived barriers included time constraints, limited interprofessional collaboration, and a lack of staff input into designing the research project and patient interventions. Perceived enablers included support from senior staff, consistent reinforcement of falls education by health professionals, and fostering patient empowerment and engagement. Recommended strategies to enhance implementation included ensuring processes were in place supporting health professional accountability, the inclusion of stakeholder input in designing the falls intervention and implementation processes, as well as leadership engagement in falls prevention education. Although health professionals play a key role in delivering evidence-based falls prevention education in hospitals, implementation can be compromised by staff capacity, capability, and opportunities for co-design with patients and researchers. Organisational buy-in to practice change facilitates the implementation of evidence-based falls prevention activities.

Implementation of Virtual Communities of Practice in Healthcare to Improve Capability and Capacity: A 10-Year Scoping Review.

Virtual communities of practice consist of individuals who use a common online platform to share professional expertise and experiences. In healthcare settings a virtual community of practice (VCoP) can optimise knowledge, skills, and the implementation of evidence-based practice. To ensure effective knowledge synthesis and translation into practice, it is essential to clarify the best methods for designing and implementing VCoPs within healthcare organisations. This scoping review aimed to identify the methods used to establish and facilitate online or digitally enabled communities of practice within healthcare organisations across the globe. Six online databases identified papers published from January 2010 to October 2020. Papers were independently screened by two reviewers using Covidence. Data were captured and analysed using a data extraction chart in Covidence. Twenty-four publications that detail methods for establishing a VCoP in healthcare were included. Few studies used a framework to establish a VCoP. It was difficult to identify details regarding methods of development and key elements such as roles, how they were coordinated, and types of technology used. Healthcare organisations can benefit from using a standardised framework for the establishment, implementation and evaluation of VCoPs to improve practice, staff engagement, and knowledge sharing.

Healthcare professional perspectives on barriers and enablers to falls prevention education: A qualitative study.

In hospitals, patient falls prevention education is frequently delivered by nurses and allied health professionals. Hospital falls rates remain high globally, despite the many systems and approaches that attempt to mitigate falling. The aim of this study was to investigate health professional views on the enablers and barriers to providing patient falls education in hospitals. Four focus groups with 23 nursing and allied health professionals were conducted at 3 hospitals. Three researchers independently coded the data and findings were analysed thematically with a descriptive qualitative approach to identify and develop themes according to barriers and enablers. Barriers included (i) limited interprofessional communication about patient falls; (ii) sub-optimal systems for falls education for patients and health professionals, and (iii) perceived patient-related barriers to falls education. Enablers to providing patient falls education included: (i) implementing strategies to increase patient empowerment; (ii) ensuring that health professionals had access to effective modes of patient education; and (iii) facilitating interprofessional collaboration. Health professionals identified the need to overcome organisational, patient and clinician-related barriers to falls education. Fostering collective responsibility amongst health professionals for evidence-based falls prevention was also highlighted.

Virtual communities of practice to improve clinical outcomes in healthcare: protocol for a 10-year scoping review.

INTRODUCTION: Virtual communities of practice (VCoPs) use a common online platform to provide healthcare professionals with the opportunity to access highly specialised knowledge, build a professional support network and promote the translation of research evidence into practice. There is limited reporting of how best to design and administer VCoPs within healthcare organisations. The primary aim of this scoping review is to identify the best methods used to establish and maintain VCoPs. Findings shall be used to develop a flexible framework to guide the establishment and facilitation of a VCoP for healthcare professionals to ensure the translation of falls prevention clinical guidelines into practice. METHODS AND ANALYSIS: A five-stage scoping review process will be followed based on Arksey and O'Malley's framework and refined by the Joanna Briggs Institute Methodology. An initial limited search of PubMed and Cumulative Index to Nursing and Allied Health Literature will identify relevant studies and assist with search term development. This will be followed by a search of five online databases to identify papers published from January 2010 until November 2020. Papers will be independently screened by two reviewers, and data extracted and analysed using a reporting framework. Qualitative data will be analysed thematically and numerical synthesis of the data will be conducted. RESULTS AND DISSEMINATION: The results of this scoping review will highlight the best ways to design and manage VCoPs in healthcare organisations. The findings will be presented at relevant stakeholder workshops, conferences and published in peer-reviewed journals.

Improving hospital falls screening and mitigation using a health professional education framework.

OBJECTIVE: Although health professional education has the potential to mitigate hospital falls risk, the best methods to develop, deliver and evaluate health professional education remain unclear. This study applied evidence-based approaches to education design to improve falls risk mitigation. DESIGN: Mixed methods using questionnaires to evaluate health professionals knowledge of evidence-based falls risk assessment and mitigation, followed by semi-structured interviews with individual health professionals. SETTING: Five large Australian hospitals. PARTICIPANTS: For each hospital, 10 clinical leaders from nursing and allied health professions were invited to participate in falls workshops. METHODS: 46 participants received a three-hour education program on the latest evidence in hospital falls risk assessment and how to implement evidence-based falls screening and management. This was based on the "4P" education model (Presage, Planning, Process and Product). They were taught practical skills to enable them to educate other health professionals. RESULTS: The education workshop significantly changed participants' views about best practice guidelines for falls screening and prevention. Participants felt more confident in assessing falls risk and judging and implementing the best mitigation strategies. They were prepared and motivated to educate others about falls prevention and satisfied with the skills gained. CONCLUSIONS: A high-quality education program grounded in a rigorous quality framework improved health professionals knowledge regarding evidence-based falls prevention. Use of evidence-based rationales for behaviour change promotes effective learning.

MammographyOnline: An evaluation of an online mammography education program for radiographers.

INTRODUCTION: In Australia, the gold standard for post graduate education in mammography is the Certificate of Clinical Proficiency in Mammography (CCPM) awarded by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT). The award has two components -academic and clinical. This paper reports on the experiences of the first online offering of the academic component, MammographyOnline (MO), by BreastScreen Victoria, Australia. Online learning is well established in health professional education at all levels of learning, however evaluation is essential to ensure its effectiveness and inform future development. METHODS: Consenting course participants completed module evaluations, and pre and post program evaluations. Course planners (n = 5) attended a 1-h focus group about the development process. Placement supervisors (n = 3) took part in a 30 min semi-structured telephone interview, identifying views of graduate performance. Survey data and rating scales were analysed descriptively. Qualitative data from surveys and interviews underwent content analysis. RESULTS: Course participants found the content of MO to be beneficial but highlighted technical issues and suggested improvements for more interactive methods of delivery. Enablers to the program's development identified by course planners, included having experienced and knowledgeable staff on-board, appropriate project management processes, and management support. Challenges expressed by course planners included staffing for the duration of the project and the burden of time and finances, though all perceived they had produced a high quality, relevant and comprehensive online programme. Supervisors recognised that MO fulfilled the requirements of the academic component of the CCPM but did not supersede the need for the clinical component. CONCLUSIONS: Despite numerous challenges associated with its development, the overwhelming view of learners, developers and supervisors was that MO is a high quality academic program of learning, that provides the theory to support and prepare radiographers for their future clinical practice. Some refinement of content, assessment tasks and technical features are required.

Hospital falls prevention with patient education: a scoping review.

BACKGROUND: Hospital falls remain a frequent and debilitating problem worldwide. Most hospital falls prevention strategies have targeted clinician education, environmental modifications, assistive devices, hospital systems and medication reviews. The role that patients can play in preventing falls whilst in hospital has received less attention. This critical review scopes patient falls education interventions for hospitals. The quality of the educational designs under-pinning patient falls education programmes was also evaluated. The outcomes of patient-centred falls prevention programs were considered for a range of hospital settings and diagnoses. METHODS: The Arksey and O'Malley (2005) framework for scoping reviews was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Eight databases, including grey literature, were searched from January 2008 until February 2020. Two reviewers independently screened the articles and data were extracted and summarised thematically. The quality of falls prevention education programs for patients was also appraised using a modified quality metric tool. RESULTS: Forty-three articles were included in the final analysis. The interventions included: (i) direct face-to-face patient education about falls risks and mitigation; (ii) educational tools; (iii) patient-focussed consumer materials such as pamphlets, brochures and handouts; and (iv) hospital systems, policies and procedures to assist patients to prevent falls. The included studies assessed falls or education related outcomes before and after patient falls prevention education. Few studies reported incorporating education design principles or educational theories. When reported, most educational programs were of low to moderate quality from an educational design perspective. CONCLUSIONS: There is emerging evidence that hospital falls prevention interventions that incorporate patient education can reduce falls and associated injuries such as bruising, lacerations or fractures. The design, mode of delivery and quality of educational design influence outcomes. Well-designed education programs can improve knowledge and self-perception of risk, empowering patients to reduce their risk of falling whilst in hospital.

End-user experiences with two incident and injury reporting systems designed for led outdoor activities - challenges for implementation of future data systems.

BACKGROUND: Injury and incident (near miss) prevention is heavily dependent upon robust and high-quality data systems. Evaluations of surveillance systems designed to report factors associated with incidents and injuries are essential to understand their value, as well as to improve their performance and efficiency. Despite, this there have been few such evaluations published in the peer-review literature. METHODS: The attitudes and experiences of industry representatives who used one of two variants of an incident and injury surveillance system to collect injury and incident data for the led outdoor activity setting were obtained through an online self-report survey following a 12-month trial. Survey respondents were 18 representatives of 33 organisations who were users of a comprehensive incident reporting and surveillance system - the Understanding and Preventing Led Outdoor Accidents Data System Software Tool (UPLOADS-ST) - and six out of 11 users of a modified system (UPLOADS-Lite). The survey collected information on user experiences in relation to system training, accessibility, ease of use, security, feedback and perceived value to the sector of collating and reporting data across organisations. FINDINGS: Only four UPLOADS-ST responding users found the system easy to use and just three considered entering incident reports to be easy. However, many considered the training on reporting incidents to be sufficient and that the incident reports contained relevant details. Fewer than half of respondents (seven for UPLOADS-ST, three for UPLOADS-Lite) believed entering data was a good use of staff time and resources. Nonetheless, a majority of respondents (seven for UPLOADS-ST, five for UPLOADS-Lite) found the reporting format easy to read and felt the information provided was useful for their organisation. CONCLUSIONS: Usability barriers to incident reporting were identified, particularly for UPLOADS-ST, including time constraints and user friendliness. The majority of users believed aggregating and reporting incident and injury data across organisations would be of value in making the led outdoor activity sector safer. Improving the utility of the surveillance systems will assist in ensuring their sustainability in the led outdoor activity sector.

Educating hospital patients to prevent falls: protocol for a scoping review.

INTRODUCTION: Falls prevention in hospitals is an ongoing challenge worldwide. Despite a wide variety of recommended falls mitigation strategies, few have strong evidence for effectiveness in reducing falls and accompanying injuries. Patient education programmes that promote engagement and enable people to understand their heightened falls risk while hospitalised are one approach. The aim of this scoping review is to examine the content, design and outcomes of patient education approaches to hospital falls prevention. As well as critiquing the role of patient education in hospital falls prevention, strategies that can be used in clinical practice shall be recommended. METHODS AND ANALYSIS: The analysis will apply the methodological framework developed by Arksey and O'Malley and refined by the Joanna Briggs Institute. An initial limited search of Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed will be completed to identify keywords and index terms. A developed search strategy of Medical Subject Headings and text words will be conducted of PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, PsychINFO, Education Resources Information Center and grey literature databases from January 2008 to current. The reference lists of included articles will be hand searched for additional studies. Two reviewers will screen the titles and abstracts independently and analyse the full text of potential articles based on the inclusion and exclusion criteria. The data will be extracted using a structured data form. Thematic analysis and numerical synthesis of the data will be conducted, and key themes will be identified. ETHICS AND DISSEMINATION: Results of this scoping review will illuminate the designs and outcomes of patient education research for hospital falls prevention in the current literature. It is anticipated that the findings will highlight best-practice educational design to inform the development of future patient-focused education for falls prevention. Study findings will be presented at relevant conferences and public forums, and published in peer-reviewed journals. Ethics approval is not required.

Factors Influencing the Implementation of a Hospitalwide Intervention to Promote Professionalism and Build a Safety Culture: A Qualitative Study.

BACKGROUND: There is widespread recognition that creating a safety culture supports high-quality health care. However, the complex factors affecting cultural change interventions are not well understood. This study examines factors influencing the implementation of an intervention to promote professionalism and build a safety culture at an Australian hospital. METHODS: The study was completed midway into the three-year intervention and involved collecting qualitative data from two sources. First, face-to-face interviews were conducted pre- and mid-intervention with a purposely selected sample. Second, a survey with three open-ended questions was completed one year into the intervention by clinical and patient support staff. Data from interviews and survey questions were analyzed using a combination of inductive and deductive approaches. RESULTS: A total of 25 participants completed preintervention interviews, and 24 took part mid-intervention. Of the 2,047 staff who completed the survey (61% response rate), 59.1% of respondents answered at least one open-ended question. Multiple interrelated factors were identified as enhancing intervention implementation. These include sustaining a favorable implementation climate, leaders consistently demonstrating behaviors that support a safety culture, increasing compatibility of working conditions with intervention aims, building confidence in systems to address unprofessional behaviors, and responding to evolving needs. CONCLUSION: Strengthening safety culture remains an enduring challenge, but this study yields valuable insights into factors influencing implementation of a multifaceted behavior change intervention. The findings provide a basis for practical strategies that health care leaders seeking cultural improvements can employ to enhance the delivery of similar interventions and address potential impediments to success.

Evaluating the cost-effectiveness of percutaneous closure of a patent foramen ovale versus medical management in patients with a cryptogenic stroke: from the UK payer perspective.

AIMS: Percutaneous closure of a patent foramen ovale (PFO) is known to lower the risk of recurrent stroke in patients with a cryptogenic stroke. However, the economic implications of transcatheter PFO closure are less well known. From a UK payer perspective, a detailed economic appraisal of PFO closure was performed for prevention of recurrent ischemic stroke in patients with a PFO who had experienced a cryptogenic stroke. MATERIALS AND METHODS: A Markov cohort model was constructed using a 5-year time-horizon with a patient mean age of 45.2 years, reflecting the characteristics reported in the REDUCE trial. Transition probabilities, clinical inputs, costs, and utility values were ascertained from published and national costing sources. Total costs, incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were calculated, utilizing a discount rate of 3.5%. A range of univariate and probabilistic sensitivity analyses were also performed. RESULTS: When applying a willingness-to-pay (WTP) threshold of £20,000/QALY in accordance with NICE guidelines, PFO closure compared with antiplatelet therapy alone showed a beneficial cost/QALY of £18,584, attained at 4 years. Applying discount rates of 0% and 6% had a negligible effect on the base-case model findings. PFO closure demonstrated a 76.9% probability of being cost-effective at a WTP threshold of £20,000/QALY at a 5-year time-horizon. LIMITATIONS: This model focused specifically on UK stroke patients and typically enrolled young (mean age <65 years old) patients. Hence, caution should be taken when comparing data vs non-UK populations, and it remains unclear how older patients might have affected cost-effectiveness findings, as the risk of paradoxical embolism can persist as patients age. CONCLUSION: Percutaneous closure of a PFO is cost-effective compared with antiplatelet therapy alone, underlining the economic benefits potentially afforded by this treatment in selected patients.