Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease.

Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.

Low- and Middle-Income Country Host Perceptions of Short-Term Experiences in Global Health: A Systematic Review.

PURPOSE: Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH). METHOD: In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes. RESULTS: Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct. CONCLUSIONS: STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.

Current Resources for Evidence-Based Practice, November 2020.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of diversity in the maternity care workforce and commentaries on reviews focused on burnout in midwifery and a cross-national comparison of guidelines for uncomplicated childbirth.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group.

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Implementation science on the margins: How do we demonstrate the value of implementation strategies?

Implementation science (IS) has developed as a field to assess effective ways to implement and disseminate evidence-based practices. Although the size and rigor of the field has improved, the economic evaluation of implementation strategies has lagged behind other areas of IS (Roberts, Healey, & Sevdalis, 2019). Beyond demonstrating the effectiveness of implementation strategies, there needs to be evidence that investments in these strategies are efficient or financially sustainable. In this editorial, we lay out conceptual challenges in applying economic evaluation to IS and the implications for conducting economic analyses in integrated primary care research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Current Resources for Evidence-Based Practice, September 2020.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of "spin" in scientific reporting and its effect on summaries and syntheses of the literature and commentaries on reviews about early versus late amniotomy as part of labor induction protocols and the economic burden associated with maternal morbidity.

How to translate scientific knowledge into practice? Concepts, models and application.

OBJECTIVES: to present the concept of Knowledge Translation and Exchange as it has been used in the international literature and in Canada, particularly. Next, to describe a renowned conceptual model to guide its implementation, entitled Knowledge-to-Action Cycle. RESULTS: we described the use of the model in the context of the municipal primary health care system in southern Brazil for the implementation of pain management strategies during vaccination. CONCLUSIONS: in this theoretical reflection, we argue that in order to promote health equity and quality of care in the Unified Health System (Brazilian SUS) it is important to translate scientific knowledge to various practice settings and create opportunities for exchange with users of this knowledge, such as health professionals, managers, policy makers, patients, family members and other stakeholders.

Cost-effectiveness Analysis of the Elder-Friendly Approaches to the Surgical Environment (EASE) Intervention for Emergency Abdominal Surgical Care of Adults Aged 65 Years and Older.

Importance: The Elder-Friendly Approaches to the Surgical Environment (EASE) initiative is a novel approach to acute surgical care for elderly patients. Objective: To determine the cost-effectiveness of EASE. Design, Setting, and Participants: An economic evaluation from the perspective of the health care system was conducted as part of the controlled before-and-after EASE study at 2 tertiary care centers, the University of Alberta Hospital and Foothills Medical Centre. Participants included elderly adults (aged ≥65 years) admitted for emergency abdominal surgery between 2014 and 2017. Data were analyzed from April 2018 to February 2019. Main Outcomes and Measures: Data were captured at both control and intervention sites before and after implementation of the EASE intervention. Resource use was captured over 6 months of follow-up and was converted to costs. Utility was measured with the EuroQol Five-Dimensions Three-Levels instrument at 6 weeks and 6 months of follow-up. The differences-in-differences method was used to estimate the association of the intervention with cost and quality-adjusted life-years. For a subset of participants, self-reported out-of-pocket health care costs were collected using the Resource Use Inventory at 6 months. Results: A total of 675 participants were included (mean [SD] age, 75.3 [7.9] years; 333 women [49.3%]), 289 in the intervention group and 386 in the control group. The mean (SD) cost per control participant was $36 995 ($44 169) before EASE and $35 032 ($43 611) after EASE (all costs are shown in 2018 Canadian dollars). The mean (SD) cost per intervention participant was $56 143 ($74 039) before EASE and $39 001 ($59 854) after EASE. Controlling for age, sex, and Clinical Frailty Score, the EASE intervention was associated with a mean (SE) cost reduction of 23.5% (12.5%) (P = .02). The change in quality-adjusted life-years observed associated with the intervention was not statistically significant (mean [SE], 0.00001 [0.0001] quality-adjusted life-year; P = .72). The Resource Use Inventory was collected for 331 participants. The mean (SE) odds ratio for having 0 out-of-pocket expenses because of the intervention, compared with having expenses greater than 0, was 15.77 (3.37) (P = .02). Among participants with Resource Use Inventory costs greater than 0, EASE was not associated with a change in spending (mean [SE] reduction associated with EASE, 19.1% [45.2%]; P = .57). Conclusions and Relevance: This study suggests that the EASE intervention was associated with a reduction in costs and no change in quality-adjusted life-years. In locations that lack capacity to implement this intervention, costs to increase capacity should be weighed against the estimated costs avoided.

Navigating Turbulent Waters: Leading Home and Community Care Practice Change during the COVID-19 Pandemic.

This case study outlines the journey of a home-care organization to support practice change during the COVID-19 crisis. The leadership attributes and organizational structures and processes required for a nimble knowledge-to-action response are explored in relation to client screening, personal protective equipment and development of virtual care. A home and community practice lens was often not evident in the literature or guidance documents. This added complexity to the process of rapidly evaluating evidence and guidance across two provinces and issuing practice direction to a widely dispersed and mobile workforce. A cross-functional clinical response team has been invaluable in the organization's pandemic response.

Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

OBJECTIVE: To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS: We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS: Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS: Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

Implementation science: What is it and why should I care?

Centuries of experience make it clear that establishing the effectiveness of a clinical innovation is not sufficient to guarantee its uptake into routine use. The relatively new field of implementation science has developed to enhance the uptake of evidence-based practices and thereby increase their public health impact. Implementation science shares many characteristics, and the rigorous approach, of clinical research. However, it is distinct in that it attends to factors in addition to the effectiveness of the clinical innovation itself, to include identifying and addressing barriers and facilitators to the uptake of evidence-based clinical innovations. This article reviews the definition, history, and scope of implementation science, and places the field within the broader enterprise of biomedical research. It also provides an overview of this Special Issue of Psychiatry Research, which introduces the principles and methods of implementation science to mental health researchers.

How to translate scientific knowledge into practice? Concepts, models and application / ¿Cómo traducir el conocimiento científico a la práctica? Conceptos, modelos y aplicación / Como traduzir o conhecimento científico à prática? Conceitos, modelos e aplicação

ABSTRACT Objectives: to present the concept of Knowledge Translation and Exchange as it has been used in the international literature and in Canada, particularly. Next, to describe a renowned conceptual model to guide its implementation, entitled Knowledge-to-Action Cycle. Results: we described the use of the model in the context of the municipal primary health care system in southern Brazil for the implementation of pain management strategies during vaccination. Conclusions: in this theoretical reflection, we argue that in order to promote health equity and quality of care in the Unified Health System (Brazilian SUS) it is important to translate scientific knowledge to various practice settings and create opportunities for exchange with users of this knowledge, such as health professionals, managers, policy makers, patients, family members and other stakeholders.

RESUMEN Objetivos: presentar el concepto de Traducción e Intercambio de Conocimiento tal como se ha utilizado en la literatura internacional y, en particular, en Canadá. A continuación, describir un modelo conceptual reconocido para guiar su implementación, titulado Ciclo del Conocimiento a la Acción. Resultados: ilustramos el uso del modelo en el contexto del sistema municipal de atención primaria de salud en el sur de Brasil para implementar estrategias de manejo del dolor durante la vacunación. Conclusiones: en esta reflexión teórica, argumentamos sobre la importancia de traducir el conocimiento científico a los diversos contextos de práctica y de crear oportunidades de intercambio con los usuarios de este conocimiento, como profesionales sanitarios, gerentes, formuladores de políticas públicas, pacientes, familias y otros grupos de interés para promover la equidad y la calidad de los cuidados en el Sistema Único de Salud.

RESUMO Objetivos: apresentar o conceito de Tradução e Intercâmbio do Conhecimento tal como vem sendo utilizado na literatura internacional e, em particular, no Canadá. A seguir, descrever um renomado modelo conceitual para orientar a sua implementação, intitulado Ciclo do Conhecimento à Ação. Resultados: ilustramos a utilização do modelo no contexto do sistema municipal de atenção básica à saúde no sul do Brasil, na implementação de estratégias de manejo da dor durante a vacinação. Conclusões: nesta reflexão teórica, argumentamos sobre a importância de se traduzir o conhecimento científico aos diversos contextos de prática e criar oportunidades de intercâmbio com os usuários desse saber, como profissionais de saúde, gestores, formuladores de políticas públicas, pacientes, familiares e demais grupos de interesse, para promover equidade e qualidade dos cuidados no Sistema Único de Saúde.

Real-World Evidence in Healthcare Decision Making: Global Trends and Case Studies From Latin America.

BACKGROUND: Real-world evidence (RWE) is increasingly used to inform health technology assessments for resource allocation, which are valuable tools for emerging economies such as in America. Nevertheless, the characteristics and uses in South America are unknown. OBJECTIVES: To identify sources, characteristics, and uses of RWE in Argentina, Brazil, Colombia, and Chile, and evaluate the context-specific challenges. The implications for future regulation and responsible management of RWE in the region are also considered. METHODS: A systematic literature review, database mapping, and targeted gray literature search were conducted to identify the sources and characteristics of RWE. Findings were validated by key opinion leaders attending workshops in 4 South American countries. RESULTS: A database mapping exercise revealed 407 unique databases. Geographic scope, database type, population, and outcomes captured were reported. Characteristics of national health information systems show efforts to collect interoperable data from service providers, insurers, and government agencies, but that initiatives are hampered by fragmentation, lack of stewardship, and resources. In South America, RWE is mainly used for pharmacovigilance and as pure academic research, but less so for health technology assessment decision making or pricing negotiations and not at all to inform early access schemes. CONCLUSIONS: The quality of real-world data in the case study countries vary and RWE is not consistently used in healthcare decision making. Authors recommend that future studies monitor the impact of digitalization and the potential effects of access to RWE on the quality of patient care.

Implementation of an Evidence-Based Practice Change to Offer Nitrous Oxide During Labor.

OBJECTIVE: The aim of this evidence-based practice change was to implement use of nitrous oxide as a pain management option during labor and to examine women's satisfaction with that option. DESIGN: Evidence-based practice change guided by the model for evidence-based practice change. SETTING: Labor and delivery unit in a tertiary medical center in the southwestern United States. PARTICIPANTS: Laboring women who met eligibility criteria were offered the option of nitrous oxide during a 2-month period. MEASUREMENTS: Process indicators to measure compliance with the practice change among staff, uptake of nitrous oxide among women, and women's satisfaction with the choice to use nitrous oxide. RESULTS: Nitrous oxide was offered to 26% (n = 55) of eligible women. Most of the 55 women who used nitrous oxide during the implementation period reported satisfaction with it and indicated that they would consider nitrous oxide for a future labor. CONCLUSION: Our experience implementing a practice change to offer nitrous oxide to laboring women indicated that use of nitrous oxide was feasible in this setting and that women were receptive to this option, were satisfied with its use, and would use nitrous oxide for a future labor.

Revisiting the Pain Resource Nurse Role in Sustaining Evidence-Based Practice Changes for Pain Assessment and Management.

BACKGROUND: Effective pain management is unlikely to occur without consistent and timely assessments. To improve assessment and management of pain, ward-based pain resource nurses were introduced in 2007 to facilitate hospital-wide evidence-based practice changes using three key targets. One-year post implementation of this quality improvement project, promising results were revealed. AIMS: The purpose of this study, 8 years post implementation, was to (a) evaluate sustained practice improvements in pain assessment and management, (b) assess current pain resource nurse knowledge and attitudes to pain, (c) explore characteristics of the pain resource nurse role, as well as (d) any perceived contextual changes regarding study findings. METHODS: A mixed-methods approach was used to address study aims. Quantitative data were collected from documentation audits and a "Knowledge and Attitudes Survey Regarding Pain." Qualitative interviews explored the characteristics of the pain resource nurse role, and a focus group discussion explored the context of change. RESULTS: Significant improvements were observed for the documentation of pain scores on admission and for each nursing shift. Survey results highlighted potential knowledge deficits in key practice areas, even though interview findings suggested that pain resource nurses provided a resource for peers, raised awareness of best practice, and imparted knowledge to other ward staff. An important facilitator for the pain resource nurse role was the ongoing collaboration and support from specific pain teams, and barriers to engage in the role were competing workload priorities, and limited awareness among other ward staff. LINKING EVIDENCE TO ACTION: Implementing and sustaining evidence-based practice change in clinical practice is challenging. Ongoing evaluation is necessary for identifying the long-term implications of practice improvement interventions and issues that influence the adoption of evidence-based practice. Strategies to address barriers, and to increase awareness and engagement of the pain resource nurse role with wider collaboration require further investigation.