Unlocking potential: a qualitative exploration guiding the implementation and evaluation of professional role substitution models in healthcare.

BACKGROUND: As role substitution models gain prominence in healthcare, understanding the factors shaping their effectiveness is paramount. This study aimed to investigate factors that impact the implementation and performance evaluation of professional role substitution models in healthcare, with a focus on understanding the variables that determine their success or failure in adoption, execution, continuity, and outcomes. METHODS: The exploratory qualitative study used semi-structured interviews with key opinion leaders, decision makers, facilitators, recipients, and frontline implementers, who had influence and involvement in the implementation of professional role substitution models. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Between November 2022 and April 2023, 39 stakeholders were interviewed. Factors influencing implementation and evaluation of allied health professional role substitution models of care aligned with the five core CFIR domains (innovation, outer setting, inner setting, individuals, implementation process) and outcome domain incorporating implementation and innovation outcomes. The six themes identified within these CFIR domains were, respectively; i) Examining the dynamics of innovation catalysts, evidence, advantages, and disadvantages; ii) Navigating the complex landscape of external factors that influence implementation and evaluation; iii) Impact of internal structural, political, and cultural contexts; iv) The roles and contributions of individuals in the process; v) Essential phases and strategies for effective implementation; and vi) The assessment of outcomes derived from allied health professional role substitution models. CONCLUSIONS: The study highlights the complex interplay of contextual and individual factors that influence the implementation and performance evaluation of professional role substitution models. It emphasises the need for collaboration among diverse stakeholders to navigate the challenges and leverage the opportunities presented by expanded healthcare roles. Understanding these multifaceted factors can contribute to the development of an empowered workforce and a healthcare system that is more efficient, effective, safe, and sustainable, ultimately benefiting patients.

Patients' acceptability of self-selected digital health services to support diet and exercise among people with complex chronic conditions: Mixed methods study.

Objective: The acceptability of being offered a choice from a suite of digital health service options to support optimal diet and exercise behaviors in adults with complex chronic conditions was evaluated. This study sought to understand many areas of acceptability including satisfaction, ease of use, usefulness and user appropriateness and perceived effectiveness. Methods: This mixed-methods study was embedded within a randomized-controlled feasibility trial providing digital health services managing diet and exercise for adults from specialist kidney and liver disease clinics. Post study surveys and semistructured interviews were used to determine patients' acceptability of the trial interventions. Quantitative (surveys) and qualitative (surveys and interviews) results were merged using integrative analysis and mapped to each construct of the modified version of the Theoretical Framework of Acceptability. Results: Seventeen interviews (intervention group) and 50 surveys (n = 24 intervention, n = 26 comparator) completed from a possible 67 participants were analyzed. In the intervention group, the survey results revealed high areas of acceptability for the digital health services including overall support received, ease of use, timely advice and feeling safe. The interviews also revealed high areas of acceptability including convenience, ability to adopt healthier behaviors and having regular interactions with health professionals. However, the interviews also revealed lower areas of acceptability as a result of absence of individualization, low digital literacy, and limitations from life circumstances. Conclusions: Recipients of digital health services that supported diet and exercise interventions found these useful, effective, and safe. Individualized care, technical support and patient confidence remain important to improve the acceptability of digital health service interventions.

Physico-chemical treatments for the removal of cyanotoxins from drinking water: Current challenges and future trends.

Cyanobacteria are highly prevalent blue-green algae that grow in stagnant and nutrient-rich water bodies. Environmental conditions, such as eutrophication and human activities, increased the cyanobacterial blooms in freshwater resources worldwide. The excessive bloom formation has also resulted in an alarming surge of cyanobacterial toxins. Prolonged exposure to cyanotoxins is a potential threat to natural ecosystems, animal and human health by the spoilage of the quality of bathing and drinking water. Various molecular and analytical methods have been proposed to monitor their occurrence and understand their global distribution. Moreover, different physical, chemical, and biological approaches have been employed to control cyanobacterial blooms and their toxins to mitigate their occurrence. Numerous strategies have been engaged in drinking water treatment plants (DWTPs). However, the degree of treatment varies greatly and is primarily determined by the source, water properties, and operating parameters such as temperature, pH, and cyanotoxin variants and levels. A comprehensive compilation of methods, from traditional approaches to more advanced oxidation processes (AOPs), are presented for the removal of intracellular and extracellular cyanotoxins. This review discusses the effectiveness of various physicochemical operations and their limitations in a DWTP, for the removal of various cyanotoxins. These operations span from simple to advanced treatment levels with varying degrees of effectiveness and differing costs of implementation. Furthermore, mitigation measures applied in other toxin systems have been considered as alternative strategies.

Measuring performance in allied health professional role substitution models of care: a clinician survey.

BACKGROUND: Professional role substitution models of care have emerged as a key strategy to address increasing healthcare demand. Gaining insights from those actively engaged in the process of these models' implementation and evaluation is pivotal to ensuring sustainability and further successful implementation. The purpose of this study was to describe allied-health clinicians' perceptions, practice, and experiences of healthcare performance evaluation in professional role substitution models of care. METHODS: Data were collected via an online platform between 22 June - 22 July 2022 using a combination of convenience and network-based sampling of allied-health clinicians involved or interested in the implementation and evaluation of professional role substitution models of care. Clinicians answered 25 questions which consisted of demographic and targeted questions regarding performance evaluation across six domains of healthcare quality (effectiveness, safety, appropriateness, access & equity, continuity of care, and cost, efficiency, productivity & sustainability). RESULTS: A total of 102 clinicians accessed the survey, with 72 providing complete survey data. Eleven allied-health professions were represented, working across twelve specialities in thirteen hospital and health services. Whilst most allied-health clinicians (93-100%) supported measuring performance in each of the six healthcare quality domains, only 26-58% were measuring these domains in practice. Allied-health leadership support (62.5%), clinician drive (62.5%), consumer engagement (50%) and medical support (46%) were enablers whilst a lack of resources (human, time, financial (47%)), healthcare performance frameworks and/or policies (40%) were identified as barriers. Given the opportunity, clinicians would invest the most financial resources in digital solutions as a core strategy to improve performance evaluation. CONCLUSIONS: Allied-health professionals expressed strong support for principles of performance evaluation, however in practice, performance evaluation is still in its infancy in professional role substitution models of care. Organisations can implement strategies that maximise the enablers whilst addressing barriers identified to improve performance evaluation in these models of care.

Implementing a virtual emergency department to avoid unnecessary emergency department presentations.

OBJECTIVE: EDs are necessary for urgent health concerns; however, many physical ED visits could be better treated in alternate settings. The present study aimed to describe the feasibility, acceptability and effectiveness of a Virtual ED to reduce unnecessary physical ED presentations at a large tertiary health service in Australia. METHODS: This observational study using the RE-AIM framework (Reach, Efficacy, Adoption, Implementation and Maintenance) evaluated the feasibility of a Virtual ED using routinely collected health service data and process-evaluation to assess intervention fidelity and adherence between April 2020 and 31 March 2022. The primary outcome for the present study was the feasibility of the Virtual ED model of care. RESULTS: The Virtual ED received 2080 direct calls for patients with a mean age of 50.3 years, with 70.4% managed in the Virtual ED alone and 29.6% referred for physical ED presentation. Of the 2080 direct referrals, 95.8% were potentially avoidable ED presentations. Of those referred, 28.3% required an admission. Of calls managed entirely by Virtual ED, 18 (1.2%) unexpectedly required a hospital admission within 48 h. General practitioner respondents rated the Virtual ED service as helpful to very helpful. The service had an average of 212 referrals per month, with a 65.2% average growth rate. The Virtual ED service was considered helpful and clinically appropriate, with a high level of ED avoidance. CONCLUSION: The Virtual ED prevented 70% of community triaged patients from presenting to the physical ED, with good uptake from all referrers, supporting the use of virtual care pathways in emergency care management.

Trust and confidence in using telehealth in people with chronic kidney disease: A cross-sectional study.

Consumer trust and confidence in telehealth is pivotal to successful service implementation and effective consultations. This cross-sectional study measured trust and confidence in telephone and video consultations and associated with experience in telehealth modalities among people with chronic kidney disease at a metropolitan hospital in Australia. Self-report data were collected using validated trust and confidence in telehealth scales and 5-point Likert responses. Non-parametric tests were used to compare trust and confidence in telephone and video consultations (Wilcoxon Matched Pairs) and associations with telehealth experience (Mann-Whitney). Of the 156 survey participants, 96.2% had used telephone consultations and 28.9% had used video. Overall trust and confidence in using telehealth were high. Confidence (range 1-5) in using telephone consultations (mean 3.75 ± 0.71) was significantly higher than video consultation (mean 3.64 ± 0.74), p = 0.039. Trust in telephone consultations (mean 3.93 ± 0.64) was significantly higher than in video consultations (mean 3.67 ± 0.66), p < 0.001. There was a significant association between experience with telephone consultations and reported levels of trust and confidence in telephone consultations. Experience with video was significantly related to trust in video consultations, but not confidence. Given the substantial difference in experience between telehealth modalities, trust and confidence may change as further exposure occurs.

A non-randomised feasibility study of a mHealth follow-up program in bariatric surgery.

BACKGROUND: Behavioural support via mobile health (mHealth) is emerging. This study aimed to assess the feasibility, acceptability, cost, and potential effect on weight of a mHealth follow-up program in bariatric surgery. METHODS: This was a non-randomised feasibility study describing intervention development and proof in the concept of a mHealth follow-up program in bariatric surgery. The study compares a prospective cohort with a historical control group and was conducted in a tertiary bariatric surgery service in Australia. The intervention group included individuals who had bariatric surgery (2019-2021) and owned a smart device, and the historical control group received usual postoperative care (2018). The intervention involved usual care plus codesigned biweekly text messages, monthly email newsletters, and online resources/videos over a 6-month period. The primary outcome measures included feasibility (via recruitment and retention rate), acceptability (via mixed methods), marginal costs, and weight 12 months postoperatively. Quantitative analysis was performed, including descriptive statistics and inferential and regression analysis. Multivariate linear regression and mixed-effects models were undertaken to test the potential intervention effect. Qualitative analysis was performed using inductive content analysis. RESULTS: The study included 176 participants (n = 129 historical control, n = 47 intervention group; mean age 56 years). Of the 50 eligible patients, 48 consented to participate (96% recruitment rate). One participant opted out of the mHealth program entirely without disclosing their reason (98% retention rate). The survey response rate was low (n = 16/47, 34%). Participants agreed/strongly agreed that text messages supported new behaviours (n = 13/15, 87%); however, few agreed/strongly agreed that the messages motivated goal setting and self-monitoring (n = 8/15, 53%), dietary change (n = 6/15, 40%), or physical activity (n = 5/15, 33%). Interviews generated four main themes (n = 12): 'motivators and expectations', 'preferences and relevance', 'reinforced information", and 'wanting social support'. The intervention reinforced information, email newsletters were lengthy/challenging to read, and text messages were favoured, yet tailoring was recommended. The intervention cost AUD 11.04 per person. The mean 12-month weight was 86 ± 16 kg and 90 ± 16 kg (intervention and historical control) with no statistically significant difference. Intervention recipients enrolled at 3 months postoperatively demonstrated a statistically significant difference in 12-month weight (p = 0.014). CONCLUSION: Although this study observed high rates of recruitment and retention, findings should be considered with caution as mHealth may have been embraced more by the intervention cohort as a result of the 2019 coronavirus pandemic. Of the various digital strategies developed and tested, the text message approach was the most acceptable; however, future intervention iterations could be strengthened through tailoring information when possible. The use of email newsletters and online resources/videos requires further testing of effectiveness to determine their value for continued use in bariatric surgery services.

Randomized Trial on the Effect of Oral Potassium Chloride Supplementation on the Thiazide-Sensitive Sodium Chloride Cotransporter in Healthy Adults.

Introduction: The putative "renal-K switch" mechanism links dietary potassium intake with sodium retention and involves activation of the sodium chloride (NaCl) cotransporter (NCC) in the distal convoluted tubule in response to low potassium intake, and suppression in response to high potassium intake. This study examined NCC abundance and phosphorylation (phosphorylated NCC [pNCC]) in urinary extracellular vesicles (uEVs) isolated from healthy adults on a high sodium diet to determine tubular responses to alteration in potassium chloride (KCl) intake. Methods: Healthy adults maintained on a high sodium (∼4.5 g [200 mmol]/d) low potassium (∼2.3 g [60 mmol]/d) diet underwent a 5-day run-in period followed by a crossover study, with 5-day supplementary KCl (active phase, Span-K 3 tablets (potassium 24 mmol) thrice daily) or 5-day placebo administrated in random order and separated by 2-day washout. Ambulatory blood pressure (BP) and biochemistries were assessed, and uEVs were analyzed by western blotting. Results: Among the 18 participants who met analysis criteria, supplementary KCl administration (vs. placebo) was associated with markedly higher levels of plasma potassium and 24-hour urine excretion of potassium, chloride, and aldosterone. KCl supplementation was associated with lower uEV levels of NCC (median fold change (KCl/Placebo) = 0.74 [0.30-1.69], P < 0.01) and pNCC (fold change (KCl/Placebo) = 0.81 [0.19-1.75], P < 0.05). Plasma potassium inversely correlated with uEV NCC (R2 = 0.11, P = 0.05). Conclusions: The lower NCC and pNCC in uEVs in response to oral KCl supplementation provide evidence to support the hypothesis of a functional "renal-K switch" in healthy human subjects.

Single Nucleotide Variants (SNVs) of Angiotensin-Converting Enzymes (ACE1 and ACE2): A Plausible Explanation for the Global Variation in COVID-19 Prevalence.

Background: Although it is common knowledge that the coronavirus disease of 2019 (COVID-19) and other viral infections have an uneven impact globally, the reasons for this are still indistinct. The absence of equivalent capacities worldwide in screening, testing, and reporting of cases is one of the ideas put forward to explain this discrepancy. The molecular developments are noteworthy, particularly the role played by single nucleotide polymorphisms (SNPs) in ACEs (ACE1 and ACE2). The virus can enter the host cell thanks to the transmembrane protein ACE2, which is a homolog of ACE1. Objectives: With a focus on the I/D genotype of ACE1 and the rs2285666 SNV of ACE2, we elucidated the prevalence of SNPs in ACE1 and ACE2 in various geographic locations. We examined the relationship between these SNPs and the global patterns of COVID-19 prevalence. Methods: 66 of the 127 articles obtained using PubMed, Google Scholar, and Google directly conformed to the search terms; geographical distribution of viral infections, the prevalence of COVID-19, ACE1, ACE2, SNPs, and prevalence of the DD genotype, and rs2285666. Results: The DD genotype of ACE1 and the rs2285666 SNV of ACE2 are vital in their gene expression and contribute greatly to viral disease susceptibility, development, and severity. There was generally a high prevalence of the DD genotype in Europe and America, where COVID-19 had a more devastating effect than in Asia and Africa. The prevalence of the SNV rs2285666 varied in the following order: East Asia> South Asia >America>Europe >Africa. However, there were conflicting agreements in the association of rs2285666 with COVID-19 susceptibility and prevalence. Conclusion: The ACE1 DD genotype and COVID-19 prevalence have been positively linked in a number of studies. The ACE2 rs2285666 SNV, however, has yielded no definitive results. To determine the relationship between these SNVs and COVID-19 incidence, more research is required.

Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials.

CONTEXT: Telehealth-delivered nutrition interventions are effective in practice; however, limited evidence exists regarding their cost-effectiveness. OBJECTIVE: To evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults with chronic disease. DATA SOURCES: PubMed, CENTRAL, CINAHL, and Embase databases were systematically searched from database inception to November 2021. Included studies were randomized controlled trials delivering a telehealth-delivered diet intervention conducted with adults with a chronic disease and that reported on cost-effectiveness or cost-utility analysis outcomes. DATA EXTRACTION: All studies were independently screened and extracted, and quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. DATA ANALYSIS: All extracted data were grouped into subcategories according to their telehealth modality and payer perspective, and were analyzed narratively. RESULTS: Twelve randomized controlled trials comprising 5 phone-only interventions, 3 mobile health (mHealth), 2 online, and 1 each using a combination of phone-online or phone-mHealth interventions, were included in this review. mHealth interventions were the most cost-effective intervention in all studies. Across all telehealth interventions and cost analyses from health service perspectives, 60% of studies were cost-effective. From a societal perspective, however, 33% of studies reported that the interventions were cost-effective. Of the 10 studies using cost-utility analyses, 3 were cost saving and more effective, making the intervention dominant, 1 study reported no difference in costs or effectiveness, and the remaining 6 studies reported increased cost and effectiveness, meaning payers must decide whether this falls within an acceptable willingness-to-pay threshold for them. Quality of study reporting varied with between 63% to 92%, with an average of 77% of CHEERS items reported. CONCLUSION: Telehealth-delivered nutrition interventions in chronic disease populations appear to be cost-effective from a health perspective, and particularly mHealth modalities. These findings support telehealth-delivered nutrition care as a clinically beneficial, cost-effective intervention delivery modality.

A mixed-method study to inform the development and implementation of eHealth in a bariatric surgery service in an Australian public hospital.

AIM: This study aimed to explore patient barriers to accessing services, current technology ownership/use and digital device preferences for accessing health information/health service delivery. Additionally, it aimed to explore the Theoretical Domains Framework and the acceptability of future eHealth solutions in bariatric surgery. METHODS: This mixed-method study (survey and semi-structured interviews) was conducted in a bariatric surgery service in an Australian public hospital. Quantitative data were analysed descriptively, and the qualitative data were deductively and inductively analysed. RESULTS: This study included 117 participants (n = 102 surveyed and n = 15 interviewed). Most participants were aged ≥51 years (n = 70, 60%), and two-thirds were female (n = 76, 65%). One in three participants reported barriers to accessing services (n = 38, 37%), including parking, travel time, and taking time off work. Most participants preferred to receive or access additional health information via email (n = 84, 82%) and were willing to engage with health professionals via email (n = 92, 90%), text messages (n = 87, 85%), and telephone (n = 85, 83%). Deductive analysis of interviews generated three themes: 'Knowledge', 'Social influence' and 'Behavioural regulation, goals and environmental resources'. The inductive analysis generated one theme: 'Seeing a place for eHealth in service delivery'. CONCLUSION: This study's findings can potentially influence the development of future eHealth solutions. Text message, email, and online approaches may be suitable for delivering further information and resources to patients, particularly regarding diet and physical activity. Online health communities are being used by patients for social support and may be worth further investigation. In addition, developing a bariatric surgery mobile application may be beneficial.

Are Digital Health Technologies and Models of Nutrition Care the Future of Chronic Kidney Disease Management?

People living with chronic kidney disease (CKD) require long-term support at varying levels of individualization, intensity, and frequency. Mobile and digital models of nutrition care can facilitate long-term behavior change, address nutrition issues proactively, reduce travel burden, and reach people without access to health care more easily. However, while traditional health delivery continues to be digitally disrupted, there are many barriers to address before mobile and digitally supported models of nutrition care can become business as usual in nephrology and nutrition care practice. This paper overviews the current evidence base concerning the past and present mobile and digital health programs to improve nutrition in CKD and highlights the novel future trends in this field. The way nutrition and dietetic care can be feasible, safe, and potentially effective when delivered using various digital and virtual technologies, including consultations, assessments, establishment of diagnoses, formulation of plans, and monitoring/reviewing clinical progress is discussed. Of the available evidence to date, these modalities appear to improve dietary sodium intake and diet quality, self-efficacy, interdialytic weight gain, and body weight. Many barriers exist to sustaining the continued and widespread adoption of digital and mobile health-supported nutrition care in CKD. These include patient-, clinician-, and health system-specific and are discussed in detail. Mobile and digital-supported models of nutrition care present an exciting opportunity to assist kidney dietitians deliver patient-centred nutrition care in CKD.

Developing a knowledge translation program for health practitioners: Allied Health Translating Research into Practice.

Background: Front-line health practitioners lack confidence in knowledge translation, yet they are often required to undertake projects to bridge the knowledge-practice gap. There are few initiatives focused on building the capacity of the health practitioner workforce to undertake knowledge translation, with most programs focusing on developing the skills of researchers. This paper reports the development and evaluation of a knowledge translation capacity building program for allied health practitioners located over geographically dispersed locations in Queensland, Australia. Methods: Allied Health Translating Research into Practice (AH-TRIP) was developed over five years with consideration of theory, research evidence and local needs assessment. AH-TRIP includes five components: training and education; support and networks (including champions and mentoring); showcase and recognition; TRIP projects and implementation; evaluation. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation Maintenance) guided the evaluation plan, with this paper reporting on the reach (number, discipline, geographical location), adoption by health services, and participant satisfaction between 2019 and 2021. Results: A total of 986 allied health practitioners participated in at least one component of AH-TRIP, with a quarter of participants located in regional areas of Queensland. Online training materials received an average of 944 unique page views each month. A total of 148 allied health practitioners have received mentoring to undertake their project, including a range of allied health disciplines and clinical areas. Very high satisfaction was reported by those receiving mentoring and attending the annual showcase event. Nine of sixteen public hospital and health service districts have adopted AH-TRIP. Conclusion: AH-TRIP is a low-cost knowledge translation capacity building initiative which can be delivered at scale to support allied health practitioners across geographically dispersed locations. Higher adoption in metropolitan areas suggests that further investment and targeted strategies are needed to reach health practitioners working in regional areas. Future evaluation should focus on exploring the impact on individual participants and the health service.

What is 'successful rehabilitation'? A multi-stakeholder nominal group technique study to inform rehabilitation outcome measurement.

OBJECTIVE: To explore how stakeholders in rehabilitation conceptualise 'successful rehabilitation', to inform the development of a minimum dataset and core outcomes for sub-acute rehabilitation. DESIGN: Qualitative consensus study using the nominal group technique. SETTING: Online focus groups. PARTICIPANTS: Consumer representatives (n = 7), clinicians (n = 15), and health service managers (n = 9) from Australia. INTERVENTION: Participants responded to the question, 'What does successful rehabilitation look like?'. Following item generation, they prioritised their top five responses, allocating 100 points across items to denote relative importance. MAIN MEASURES: Prioritised responses were analysed across stakeholder groups using qualitative content analysis. RESULTS: Ten themes were identified. 'Successful rehabilitation' is: (1) person and family centred; (2) effective; (3) inter-professional; (4) accessible; (5) goal oriented with meaningful outcomes; (6) connected to the continuum of care; (7) evidence-based and supportive of innovation and research; (8) appropriately funded and skilled; (9) satisfying and engaging; and (10) safe. CONCLUSIONS: Stakeholder-defined 'successful rehabilitation' aligned with principles of value-based care and evidence-based rehabilitation. Provision and receipt of person and family centred care was the most important indicator of successful rehabilitation. Measures of success should include indicators of structure, process, outcome, and experience, and be conducted at multiple time-points.

Patient Preferences for Attributes that Characterise Alternative Models of Care in Gastroenterology: A Discrete Choice Experiment.

OBJECTIVES: Increased demand for gastroenterology services has resulted in growing waitlists, with patients at risk of exceeding clinically recommended wait-times. Given limited healthcare resources, expanded scope models of care are an option to help address this demand, but little is known about patient preferences for these models of care. METHODS: Low-risk gastroenterology patients (n = 1198) referred to an outpatient tertiary service in Australia over a 2-year period were invited to participate in an unlabelled discrete choice experiment with seven attributes: primary healthcare professional, wait-time, continuity of care, consultation length, manner and communication skills, reassurance, and cost. These were developed using qualitative research, literature review, and stakeholders' experiences. A d-efficient fractional design was used to construct four blocks of 12 choice sets, with two alternatives. A 13th choice set was included as a data and quality check. Latent class and mixed logit regression were used for analysis. The resulting preference parameters for individual attributes were then used to calculate willingness to pay and willingness to wait. RESULTS: Overall, the model based on the 347 respondents suggested no strong preference for professional background. All other attributes were statistically significant predictors of preference (p < 0.001), with respondents willing to make significant trade-offs (time and cost) before accepting deterioration in attributes. There was strong emphasis on manner and communication skills, with a clinician who listens and provides good explanations overwhelmingly the most important attribute. Latent class analysis identified two patient segments who differed in their preference for the primary treating healthcare professional (doctor or dietitian) based on exposure to either traditional medical or non-medical professional role substitution model. CONCLUSIONS: Patients have strong but varied preferences for gastroenterology services based on whether they have been exposed to expanded scope models of care. Design and implementation of new models of care need to consider strategies to overcome any perceived loss in utility or deterioration in healthcare quality for those unfamiliar with professional role substitution.

PREBIOTIC: a study protocol of a randomised controlled trial to assess prebiotic supplementation in kidney transplant recipients for preventing infections and gastrointestinal upset - a feasibility study.

BACKGROUND: Modulating the microbiota in the large intestine of kidney transplant recipients through prebiotic supplementation may prevent infectious complications from occurring. To date, there have been no interventional trials which have investigated this novel treatment in kidney transplantation. The aim of PREBIOTIC is to assess the feasibility of performing a randomised controlled trial of prebiotics in reducing infections and gastrointestinal symptoms in kidney transplant recipients. METHODS: Sixty kidney transplant patients will be recruited to a double-blind, placebo-controlled, randomised feasibility trial. Patients will be provided with prebiotic therapy or placebo for 4 to 6 weeks. Outcomes will include recruitment, adherence, tolerance, retention, laboratory parameters (including serum indoxyl sulphate, ρ-cresyl sulphate and stool collection), patients' self-assessed quality of life, gastrointestinal symptoms and clinical outcomes. DISCUSSION: This trial will assess the feasibility of prebiotic supplementation in kidney transplant recipients. Prebiotics not only may alter the gut microbiota and their inherent metabolism and production of uraemic toxins but also may prevent infections from occurring in kidney transplant recipients. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number ACTRN12618001057279p. The date of registration was 25th June 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375370&isReview=true .

Patients' experiences with rehabilitation care: a qualitative study to inform patient-centred outcomes.

PURPOSE: To explore patients' experiences with rehabilitation, with a particular focus on outcomes that are perceived to be of value. MATERIALS AND METHODS: Semi structured interviews were conducted with adults who recently had rehabilitation for a chronic health condition in a hospital or community setting. Banja's definition of rehabilitation (personally fulfilling, socially meaningful and functionally effective) informed the enquiry and interpretation of the findings. Thematic analysis was used to categorise the data into codes and themes. RESULTS: 16 people (40-84 years, 69% male, n = 11) participated in individual telephone-interviews, describing their perspectives on what mattered to them about rehabilitation. The themes generated from the data suggested that participants focused on important social, functional and personal outcomes, but also required two fundamental features in their rehabilitation, namely a personalised and relational experience and a clear understanding of their own progress delivered in a way that is meaningful to them. CONCLUSIONS: People who undertake rehabilitation express diverse expectations when assessing their outcomes and progress, although common elements could be identified. Participants valued a number of key features about the delivery and evaluation of their rehabilitation. These features revolved around the personalisation of the process and having clarity about progress.Implications for rehabilitationRehabilitation therapists should encourage ongoing personalised discussions about progress to promote clear and shared understanding of what clients and therapists expect, alongside the use of current available measures.Rehabilitation therapists should consider providing opportunities for participants to self-reflect about their experiences and modify their goals based on personal progress and deeper understanding of their circumstances.Rehabilitation therapists should consider assessing the extent to which the individual feels satisfied with and capable of achieving these outcomes before departing from the rehabilitation service.Overall, rehabilitation teams should think about spending more time with the patient to prioritise and understand their individual goals and values.

Consumers' Perspectives and Experiences of Prebiotics and Probiotics for Gut Health in Chronic Kidney Disease.

OBJECTIVES: Nutrition supplementation, including prebiotics and probiotics, is a therapeutic strategy for modulating the gut microbiome in chronic kidney disease (CKD). However, the acceptability of gut-targeted supplements in this population remains largely unexplored. This study aims to describe the perceptions of nutrition supplementation, and the acceptability and experiences of pre- and probiotics in adults with Stage 3-4 CKD. DESIGN AND METHODS: Semi-structured interview study of adults with Stage 3-4 CKD (n = 30), aged 41-80 (mean 68) years, who completed a 12-month prebiotic and probiotic intervention or placebo, were interviewed between January and March 2019. Interviews were transcribed verbatim and analyzed thematically. RESULTS: Five themes were identified: integrating and sustaining routine supplementation (flexibility in prescription of prebiotics and probiotics, fitting in with regular routines); striving for health benefits (hoping to improve kidney health, hoping to improve general health, confirming health benefits); facilitating pre- and probiotic supplementation (perceiving pre- and probiotics as safe, side-effects from taking pre- and probiotics); empowering knowledge (valuing the opportunity to increase knowledge of gut health); and considerations for future use (questioning credibility of health claims, average palatability of prebiotic powder, cost concerns). CONCLUSIONS: Adults with Stage 3-4 CKD found pre- and probiotic supplements to be acceptable and complementary gut-targeted supplements. Individual preferences for nutrition supplementation should be considered alongside health knowledge to enhance uptake and adherence in practice.