An exploration of available methods and tools to improve the efficiency of systematic review production: a scoping review.

BACKGROUND: Systematic reviews (SRs) are time-consuming and labor-intensive to perform. With the growing number of scientific publications, the SR development process becomes even more laborious. This is problematic because timely SR evidence is essential for decision-making in evidence-based healthcare and policymaking. Numerous methods and tools that accelerate SR development have recently emerged. To date, no scoping review has been conducted to provide a comprehensive summary of methods and ready-to-use tools to improve efficiency in SR production. OBJECTIVE: To present an overview of primary studies that evaluated the use of ready-to-use applications of tools or review methods to improve efficiency in the review process. METHODS: We conducted a scoping review. An information specialist performed a systematic literature search in four databases, supplemented with citation-based and grey literature searching. We included studies reporting the performance of methods and ready-to-use tools for improving efficiency when producing or updating a SR in the health field. We performed dual, independent title and abstract screening, full-text selection, and data extraction. The results were analyzed descriptively and presented narratively. RESULTS: We included 103 studies: 51 studies reported on methods, 54 studies on tools, and 2 studies reported on both methods and tools to make SR production more efficient. A total of 72 studies evaluated the validity (n = 69) or usability (n = 3) of one method (n = 33) or tool (n = 39), and 31 studies performed comparative analyses of different methods (n = 15) or tools (n = 16). 20 studies conducted prospective evaluations in real-time workflows. Most studies evaluated methods or tools that aimed at screening titles and abstracts (n = 42) and literature searching (n = 24), while for other steps of the SR process, only a few studies were found. Regarding the outcomes included, most studies reported on validity outcomes (n = 84), while outcomes such as impact on results (n = 23), time-saving (n = 24), usability (n = 13), and cost-saving (n = 3) were less often evaluated. CONCLUSION: For title and abstract screening and literature searching, various evaluated methods and tools are available that aim at improving the efficiency of SR production. However, only few studies have addressed the influence of these methods and tools in real-world workflows. Few studies exist that evaluate methods or tools supporting the remaining tasks. Additionally, while validity outcomes are frequently reported, there is a lack of evaluation regarding other outcomes.

How is the use of research evidence in health policy perceived? A comparison between the reporting of researchers and policy-makers.

BACKGROUND: The use of health policy and systems research (HPSR) to inform health policy-making is an international challenge. Incorporating HPSR into decision-making primarily involves two groups, namely researchers (knowledge producers) and policy-makers (knowledge users). The purpose of this study was to compare the perceptions of Israeli health systems and policy researchers and health services policy-makers regarding the role of HPSR, factors influencing its uses and potential facilitators and barriers to HPSR, and implementation of knowledge transfer and exchange (KTE) activities. METHODS: A cross-sectional survey was administered to researchers and policy-makers in Israel. The survey consisted of seven closed questions. Descriptive analyses were carried out for closed-ended questions and comparative analysis were conducted between groups using the χ2 test. RESULTS: A total of 37 researchers and 32 policy-makers responded to the survey. While some views were in alignment, others showed differences. More policy-makers than researchers perceived that the use of HPSR in policy was hindered by practical implementation constraints, whereas more researchers felt that its use was hindered by a lack of coordination between knowledge producers and users. A larger percentage of policy-makers, as compared to researchers, reported that facilitators to the KTE process are in place and a larger percentage of researchers perceived barriers within the KTE environment. A larger percentage of policy-makers perceived KTE activities were in place as compared to researchers. Results also showed large differences in the perceptions of the two groups regarding policy formulation and which organisations they perceived as exerting strong influence on policy-making. CONCLUSIONS: This research demonstrated that there are differences in the perceptions of knowledge producers and users about the process of KTE. Future work should focus on minimising the challenges highlighted here and implementing new KTE activities. These activities could include making the researchers aware of the most effective manner in which to package their results, providing training to policy-makers and assuring that policy-makers have technical access to appropriate databases to search for HPSR. These results underscore the need for the groups to communicate and clarify to each other what they can offer and what they require.

Addressing overuse of health services in health systems: a critical interpretive synthesis.

BACKGROUND: Health systems are increasingly focusing on the issue of 'overuse' of health services and how to address it. We developed a framework focused on (1) the rationale and context for health systems prioritising addressing overuse, (2) elements of a comprehensive process and approach to reduce overuse and (3) implementation considerations for addressing overuse. METHODS: We conducted a critical interpretive synthesis informed by a stakeholder-engagement process. The synthesis identified relevant empirical and non-empirical articles about system-level overuse. Two reviewers independently screened records, assessed for inclusion and conceptually mapped included articles. From these, we selected a purposive sample, created structured summaries of key findings and thematically synthesised the results. RESULTS: Our search identified 3545 references, from which we included 251. Most articles (76%; n = 192) were published within 5 years of conducting the review and addressed processes for addressing overuse (63%; n = 158) or political and health system context (60%; n = 151). Besides negative outcomes at the patient, system and global level, there were various contextual factors to addressing service overuse that seem to be key issue drivers. Processes for addressing overuse can be grouped into three elements comprising a comprehensive approach, including (1) approaches to identify overused health services, (2) stakeholder- or patient-led approaches and (3) government-led initiatives. Key implementation considerations include the need to develop 'buy in' from stakeholders and citizens. CONCLUSIONS: Health systems want to ensure the use of high-value services to keep citizens healthy and avoid harm. Our synthesis can be used by policy-makers, stakeholders and researchers to understand how the issue has been prioritised, what approaches have been used to address it and implementation considerations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014013204 .

Nurses' Perceptions on the Overuse of Health Services: A Qualitative Study.

PURPOSE: To examine whether nurses in Israel think there is overuse of health services, the reasons behind the issue, and ways to reduce the overuse. DESIGN: This was a qualitative study using semistructured interviews. A convenience sample of community care nurses from health clinics across Israel was interviewed. Interviews focused on common areas of overuse, outcomes of overuse, causes of overuse, and potential ways to address the issue. Interviews were recorded, transcribed, and analyzed thematically. FINDINGS: Overuse of antibiotics, imaging, blood tests, and prenatal surveillance were cited as main areas of health service overuse. Participants stated that negative outcomes of overuse could be seen at patient, health system, and population levels. Factors influencing overuse included patient satisfaction, physician fears, and insecurities. Potential interventions included improving physicians' diagnostic confidence, increasing appointment times, providing patients with more treatment information, and implementing a unified computerized system across medical institutions. CONCLUSIONS: Nurses mentioned physicians and patients as main actors in influencing overuse; hence, those populations should be researched further. The health system was identified as the responsible party to address the issue. Health system leaders must consider potential barriers, and investigate interventions that match current culture and context within the health system. CLINICAL RELEVANCE: Nurses can play an essential role in limiting overuse and mitigating subsequent harms to patients.

Making Wise Choices in Health Provision: Initial Exploration of Nurse Perceptions in Israel.

Overuse of health services drives up costs while affecting quality of care. It can also harm patients physically and psychologically through invoking duplicate testing, unnecessary procedures, and psychological stress. The purpose of this study was to understand nurses' perceptions of health care overuse. Nurses perceived that physicians' main considerations when ordering tests are to get additional data to strengthen the diagnosis and "just to be safe." Fear of litigation and patients' desires were important factors. Implementing interventions to reduce overuse will create a more efficient and effective system.

Examining the use of health systems and policy research in the health policymaking process in Israel: views of researchers.

BACKGROUND: All too often, health policy and management decisions are made without making use of or consulting with the best available research evidence, which can lead to ineffective and inefficient health systems. One of the main actors that can ensure the use of evidence to inform policymaking is researchers. The objective of this study is to explore Israeli health systems and policy researchers' views and perceptions regarding the role of health systems and policy research (HSPR) in health policymaking and the barriers and facilitators to the use of evidence in the policymaking process. METHODS: A survey of researchers who have conducted HSPR in Israel was developed. The survey consisted of a demographics section and closed questions, which focused on support both within the researchers' organisations and the broader environment for KTE activities, perceptions on the policymaking process, and the potential influencing factors on the process. The survey was sent to all health systems and policy researchers in Israel from academic institutions, hospital settings, government agencies, the four health insurance funds, and research institutes (n = 107). All responses were analyzed using descriptive statistics. For close-ended questions about level of agreement we combined together the two highest categories (agree or strongly agree) for analysis. RESULTS: Thirty-seven respondents participated in the survey. While many respondents felt that the use of HSPR may help raise awareness on policy issues, the majority of respondents felt that the actual use of HSPR was hindered for many reasons. While facilitators do exist to support the use of research evidence in policymaking, numerous barriers hinder the process such as challenges in government/provider relations, policymakers lacking the expertise for acquiring, assessing, and applying HSPR and priorities in the health system drawing attention away from HSPR. Furthermore, it is perceived by a majority of respondents that the health insurance funds and the physician organisations exert a strong influence in the policymaking process. CONCLUSIONS: Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of evidence-informed policy in an organised and systematic way. Future research should examine the perceptions of policymakers in Israel and thus we can gain a broader perspective on where the actual issues lie.

The role of nurses and nurse leaders on realizing the clinical, social, and economic return on investment of nursing care.

There is a limited understanding of the significance and the potential contribution that nursing can make through practice, policy, science, and profession to the global health agenda. In this article, we present some of the evidence to demonstrate the clinical, social, and economic returns on investment in nursing. We conclude by addressing the issues that nurse and system leaders need to address in order to achieve these returns on investments, and unless nurses get involved at the leadership level, these returns on investment will not be attained.

Health systems and policy research evidence in health policy making in Israel: what are researchers' practices in transferring knowledge to policy makers?

BACKGROUND: Ensuring the use of research evidence in health system management and policy decisions is an important challenge in this century. Knowledge transfer and exchange (KTE) has emerged as a paradigm to address the challenges and start closing the 'know-do' gap. This area of work is gaining momentum in most developed countries, yet, to date, no work has been performed in Israel within this area. The purpose of this study was to identify which KTE activities health systems and policy researchers in Israel have undertaken. METHODS: A cross-sectional web-based survey of researchers who have conducted health systems and policy research in Israel was developed. The survey consisted of a demographics section, quantitative scales, and open-ended questions. The survey was sent to all health systems and policy researchers in Israel (n = 125). RESULTS: The study response rate (28%) was relatively low as compared to other studies in the same field (range of 42% to 88%). Our survey found that more than a third of the health systems and policy researchers in Israel reported that they were frequently or always involved in the following KTE activities: interactions with target audience through the research process (i.e., during developing a research question or executing the research; 35% to 42%) or through formal or informal meetings during conferences, workshops, or conversations (40%). Less than half of the health systems and policy researchers in Israel are engaged in bridging activities aimed to facilitate target audiences to use research. CONCLUSIONS: This is a fairly new area in Israel and therefore the level of engagement of researchers in KTE activities is not very high. The low response rates could be because KTE is a new field in Israel and minimal KTE initiatives have been undertaken. It is preferable to have higher response rates, yet, after several initiatives, this was the outcome. While the findings are relevant, they may not reflect the total population of health system and policy researchers in Israel. Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of KTE in an organized and systematic way.

The effects of shared decision making on health outcomes, health care quality, cost, and consultation time: An umbrella review.

OBJECTIVE: To review the effects of shared decision making (SDM) on health outcomes, health care quality, cost, and consultation time METHODS: We conducted an umbrella review and searched systematic reviews on SDM from PubMed, CINHAL, and Web of Science. We included reviews on SDM interventions used in a health care setting with patients. We assessed the eligibility of retrieved articles and evaluated whether the review addressed Consolidated Framework for Implementation Research (CFIR) characteristics. RESULTS: Out of 3678 records, 48 reviews were included. Half of the reviews focused exclusively on RCT studies (n = 21). A little less than half were focused specifically on decision aids (n = 23). Thirty-two reviews discussed CFIR characteristics explicitly or implicitly; the majority of which were specific to intervention characteristics. Reviews tended to cluster around patient populations and tended to be low or critically low to moderate in their quality. Reviews of SDM on health outcomes, health care quality, cost, and consultation time were highly uncertain but often ranged from neutral to positive. CONCLUSIONS: We observed that SDM implementation did not typically increase costs or increase consultation time while having some neutral to positive benefits on outcomes and quality for certain populations. Gaps in knowledge remain including better research on the climate where SDM is most effective.

An Evaluation of the Impact of an OPEN Stewardship Generated Feedback Intervention on Antibiotic Prescribing among Primary Care Veterinarians in Canada and Israel.

An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.

Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey.

BACKGROUND: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Avoidable Care Transitions: A Consensus-Based Definition Using a Delphi Technique.

Background and Objectives: Older adults are at increased risk of frequent transitions between care settings, even though some care transitions are avoidable. The term "avoidable care transitions" is not clearly defined in the research literature. This study aimed to find a consensus-based definition for "avoidable care transitions." Research Design and Methods: This study was conducted as part of the TRANS-SENIOR research network. A 4-round Delphi survey was based on a literature review that identified existing definitions of "avoidable care transitions." Articles in MEDLINE via PubMed and CINAHL were searched. In total 95 references were included, and 106 definitions were identified. Definitions were coded to find themes, resulting in 3 themes with 2 codes for each. Results: In total, 99 experts from 9 countries were invited, and the response rates in Delphi Rounds 1, 2, 3, and 4 were 37.5%, 19.1%, 33.3%, and 23.3%, respectively. Upon reaching the predefined minimum of 90% agreement, the following definition was declared as final: "Avoidable care transitions (a) are without significant patient-relevant benefits or with a risk of harm outweighing patient-relevant benefits and/or (b) are when a comparable health outcome could be achieved in lower resource settings using the resources available in that place/health care system, and/or (c) violate a patient's/informal caregiver's preference or an agreed care plan." Discussion and Implications: Consensus on a definition for "avoidable care transitions" was reached by a multidisciplinary and international panel of experts comprising researchers and providers. The resulting definition consists of 3 distinct dimensions relating to the balance of benefit and harm to a patient, resource consumption, and a patient's or informal caregiver's preferences. The new definition might enhance the common understanding of avoidable care transitions and is now ready for application in research and quality and safety management in health care.

Perceptions of shared decision making in gastroenterology and inflammatory bowel disease: A qualitative analysis.

OBJECTIVE: Shared decision-making (SDM) is the partnership and discussion between clinicians and patients to make an appropriate decision based on scientific evidence and patient preferences. Many benefits are associated with SDM; however, little is known about its awareness or use by inflammatory bowel disease (IBD) clinicians in gastroenterology departments across Israel. This study aims to identify barriers and facilitators in implementing SDM as standard practice to achieve optimal disease management and personalized care for patients with IBD. METHODS: Sixteen semi-structured interviews were conducted with IBD clinicians across Israel to identify the barriers and facilitators for SDM use. An interview guide was developed, based on the systematic approach of the Theoretical Domain Framework (TDF). Interview transcripts were coded into theoretical domains to identify factors that may impact SDM. RESULTS: Sixteen gastroenterologists from nine different hospitals were interviewed. Common TDF domains that presented as barriers were: knowledge, skills, social/professional role and identity, environmental context and resources, and reinforcement. Most participants had never heard the precise term "shared decision making" and lacked formal training on SDM. CONCLUSION: This study identified key barriers and facilitators to SDM in IBD clinics across Israel. Main barriers of SDM include limited or nonexistent training; clinicians were unaware of SDM guidelines or techniques. The main facilitators of SDM were clinicians' social and professional role and identity and their beliefs about the influence of IBD and/or CD. PRACTICE IMPLICATIONS: These influencing factors and TDF domains identified provide a basis for developing future interventions to improve the implementation of SDM within IBD management.

Delphi survey on the most promising areas and methods to improve systematic reviews' production and updating.

BACKGROUND: Systematic reviews (SRs) are invaluable evidence syntheses, widely used in biomedicine and other scientific areas. Tremendous resources are being spent on the production and updating of SRs. There is a continuous need to automatize the process and use the workforce and resources to make it faster and more efficient. METHODS: Information gathered by previous EVBRES research was used to construct a questionnaire for round 1 which was partly quantitative, partly qualitative. Fifty five experienced SR authors were invited to participate in a Delphi study (DS) designed to identify the most promising areas and methods to improve the efficient production and updating of SRs. Topic questions focused on which areas of SRs are most time/effort/resource intensive and should be prioritized in further research. Data were analysed using NVivo 12 plus, Microsoft Excel 2013 and SPSS. Thematic analysis findings were used on the topics on which agreement was not reached in round 1 in order to prepare the questionnaire for round 2. RESULTS: Sixty percent (33/55) of the invited participants completed round 1; 44% (24/55) completed round 2. Participants reported average of 13.3 years of experience in conducting SRs (SD 6.8). More than two thirds of the respondents agreed/strongly agreed the following topics should be prioritized: extracting data, literature searching, screening abstracts, obtaining and screening full texts, updating SRs, finding previous SRs, translating non-English studies, synthesizing data, project management, writing the protocol, constructing the search strategy and critically appraising. Participants have not considered following areas as priority: snowballing, GRADE-ing, writing SR, deduplication, formulating SR question, performing meta-analysis. CONCLUSIONS: Data extraction was prioritized by the majority of participants as an area that needs more research/methods development. Quality of available language translating tools has dramatically increased over the years (Google translate, DeepL). The promising new tool for snowballing emerged (Citation Chaser). Automation cannot substitute human judgement where complex decisions are needed (GRADE-ing). TRIAL REGISTRATION: Study protocol was registered at https://osf.io/bp2hu/ .

Evidence-Informed Policy-Making: Are We Doing Enough? Comment on "Examining and Contextualizing Approaches to Establish Policy Support Organizations - A Mixed Method Study".

In their study of manifestations of policy support organizations (PSOs), Al Sabahi et al found that PSOs are united in their goal to support evidence-informed policy-making (EIPM), albeit with differing approaches. Their article is an important contribution to the body of research on evidence utilization and implementation. The unprecedented evidence climate presented by coronavirus disease 2019 (COVID-19) provides a unique window to motivate EIPM implementation. Research such as Al Sabahi and colleagues must prompt a dialogue regarding how best to address some of the current shortcomings in the field of EIPM. Monitoring and evaluation of best practices in EIPM is scarce. EIPM uptake is unsatisfactory, and the scientific community needs to ask itself why that is and what can be done. And, we should strive to develop a gradient that discerns between the convenient and the essential so countries can evaluate and pursue the policies to best address their greatest pain points through evidence.

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research.

BACKGROUND: Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs. METHODS: We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs. CONCLUSION: We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions. TRIAL REGISTRATION: PROSPERO: CRD42021252715 .

Nurse practitioner integration: Conceptual development to enhance application in policy and research.

BACKGROUND: Nurse practitioners (NPs) have been introduced across the world to improve care quality and solve provider shortages. Realizing these benefits relies on their successful integration into health care systems. Although NP integration has been discussed extensively, the concept is defined inconsistently. Literature, therefore, cannot be synthesized to create policy recommendations for management and policymakers to plan for and advance NP integration. OBJECTIVES: To describe and define NP integration and enhance its applicability in research and policy. DATA SOURCES: A modified Walker and Avant concept analysis was used to develop a conceptual model of NP integration. Data were extracted and synthesized from 78 sources referencing the concept. CONCLUSIONS: Nurse practitioner integration was operationally defined as the multilevel process of incorporating NPs into the health care system so that NPs can practice to their full scope, education, and training and contribute to patient, system, and population needs. The attributes of NP integration are: 1) achievable goal; 2) process; 3) introduction of the role; 4) incorporation into organizational care models; 5) challenging traditional ideologies; 6) ability to function; 7) provide high-quality care; and 8) improve outcomes, sustainability, and health system transformation. Seventeen facilitators/barriers affecting NP integration were identified. Three health care system levels at which integration occurs were identified- macro , meso , and micro . IMPLICATIONS FOR PRACTICE: Findings will inform managers, policymakers, and stakeholders about NP integration to aid in planning and policy development. Results can be used to inform research on barriers and facilitators to NP integration.

Desirable attributes of theories, models, and frameworks for implementation strategy design in healthcare: a scoping review protocol.

Background: Implementation strategies can facilitate the adoption of evidence-based practices and policies. A wide range of theoretical approaches-theories, models, and frameworks-can be used to inform implementation strategy design in different ways (e.g., guiding barrier and enabler assessment to implementing evidence-based interventions). While selection criteria and attributes of theoretical approaches for use in implementation strategy design have been studied, they have never been synthesized. Furthermore, theoretical approaches have never been classified according to desirable criteria and attributes for use in implementation strategy design. This scoping review aims to a) identify the literature reporting on the selection of theoretical approaches for informing implementation strategy design in healthcare and b) understand the suggested use of these approaches in implementation strategy design. Methods: The Joanna Briggs Institute methodological guidelines will be used to conduct this scoping review. A search of three bibliographical databases (MEDLINE, Embase, CINAHL) will be conducted for peer-reviewed discussion, methods, protocol, or review papers. Data will be managed using the Covidence software. Two review team members will independently perform screening, full text review and data extraction. Results: Results will include a list of selection criteria and attributes of theoretical approaches for use in research on implementation strategy design. Descriptive data regarding selection criteria and attributes will be synthesized graphically and in table format. Data regarding the suggested use of theoretical approaches in implementation strategy design will be presented narratively. Conclusions: Results will be used to classify existing theoretical approaches according to the attributes and selection criteria identified in this scoping review. Envisioned next steps include an online tool that will be created to assist researchers in selecting theories, models, and frameworks for implementation strategy design.

Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China.

BACKGROUND: Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. METHODS: In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. RESULTS: Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. CONCLUSION: The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.