Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial.

Importance: Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. Objective: To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. Design, Setting, and Participants: This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Interventions: Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Main Outcomes and Measures: Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Results: Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (ß = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (ß = 2.0; 95% CI, -1.7 to 5.7; P = .29). Conclusions and Relevance: In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. Trial Registration: ClinicalTrials.gov Identifier: NCT02738944.

Patient-Reported Outcomes of Pain and Related Symptoms in Integrative Oncology Practice and Clinical Research: Evidence and Recommendations.

Pain is a primary concern among patients with cancer and cancer survivors. Integrative interventions such as acupuncture, massage, and music therapy are effective nonpharmacologic approaches for cancer pain with low cost and minimal adverse events. Patient-reported outcomes (PROs) that have been validated in many clinical and research settings can be used to evaluate pain intensity, associated symptom burden, and quality of life. Clearly defined, reliable PROs can improve patient satisfaction and symptom control. As integrative oncology continues to evolve and expand, cancer-related pain PROs must be standardized to accurately guide clinicians and researchers. Well-validated pain PROs, such as the Brief Pain Inventory, are among the most commonly used for pain intensity assessment. Multiple symptom assessment tools such as the MD Anderson Symptom Inventory, the Memorial Symptom Assessment Scale, the Edmonton Symptom Assessment System, and the Patient-Reported Outcomes-Common Terminology Criteria for Adverse Events measurement system can also capture pain-associated symptom burden. Electronic PROs provide flexibility in collecting and analyzing PRO data. Clinical trials using carefully selected PROs and rigorous statistical analysis plans are fundamental to conducting high-quality integrative oncology research and promoting utilization of effective integrative interventions to improve patient outcomes. In this review, we aim to summarize current, validated PROs specific to cancer-related pain to aid integrative oncology clinicians and researchers in patient care and in study design and implementation.

Community engagement in Health Technology Assessment and beyond: from guests in the process to hosts.

In Health Technology Assessment (HTA), clinical and economic evidence are assessed in the regulatory and reimbursement environments, with community input considered as complementary to this. Stakeholders are calling for more meaningful community engagement, but this will not be reached without a significant shift. The Centre for Community-Driven Research (CCDR) is a nonprofit organization bringing much needed change to the way we think about community engagement in health. This article is based on CCDR's experience and outlines three system changes needed to advance community engagement in decisions about health and HTA. This paper comes from the perspective of engaging everyday people in the process as opposed to representation on panels and committees. The three key areas of change that are discussed include building holistic evidence, creating supportive environments, and infrastructure for community engagement, with the term community referring to people affected by disease or health conditions and their carers/families.

Two-eyed seeing of the integration of oral health in primary health care in Indigenous populations: a scoping review.

BACKGROUND: Indigenous people experience significant poor oral health outcomes and poorer access to oral health care in comparison to the general population. The integration of oral health care with primary health care has been highlighted to be effective in addressing these oral health disparities. Scoping studies are an increasingly popular approach to reviewing health research evidence. Two-eyed seeing is an approach for both Western and Indigenous knowledge to come together to aid understanding and solve problems. Thus, the two-eyed seeing theoretical framework advocates viewing the world with one eye focused on Indigenous knowledge and the other eye on Western knowledge. This scoping review was conducted to systematically map the available integrated primary oral health care programs and their outcomes in these communities using the two-eyed seeing concept. METHODS: This scoping review followed Arksey and O'Malley's five-stage framework and its methodological advancement by Levac et al. A literature search with defined eligibility criteria was performed via several electronic databases, non-indexed Indigenous journals, Indigenous health organizational websites, and grey literature. The charted data was classified, analyzed, and reported using numeral summary and qualitative content analysis. The two-eyed seeing concept guided the interpretation and synthesis of the evidence on approaches and outcomes. RESULTS: A total of 29 publications describing 30 programs conducted in Australia and North America from 1972 to 2019 were included in the final analysis. The following four program categories emerged from the analysis: oral health promotion and prevention programs (n = 13), comprehensive dental services (n = 13), fly in, fly out dental services (n = 3), and teledentistry (n = 1). Biomedical approaches for integrated primary oral health care were leadership and governance, administration and funding, capacity building, infrastructure and technology, team work, and evidence-based practice. Indigenous approaches included the vision for holistic health, culturally appropriate services, community engagement, shared responsibility, and cultural safety. The program outcomes were identified for biological, mental, and emotional dimensions of oral health; however, measurement of the spiritual dimension was missing. CONCLUSION: Our results suggest that a multiple integrated primary oral health care approach with a particular focus on Indigenous culture seems to be efficient and relevant in improving Indigenous oral health.

A protocol for evaluating a multi-level implementation theory to scale-up obstetric triage in referral hospitals in Ghana.

BACKGROUND: Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan. METHODS: An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions. A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability. DISCUSSION: The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the "know-do" gap. Every woman and every newborn deserves a safe and positive birth experience. Yet in many parts of the world, this goal is often more aspiration than reality. In 2006, Kybele, a US-based non-governmental organization, began working with the Ghanaian government to improve the quality of obstetric and newborn care in a large hospital in Greater Accra. One successful program was the development of a triage system that would help midwives rapidly assess pregnant women to determine who needed what kind of care and develop risk-based care plans. The program was then replicated in another large hospital in the Greater Accra region, where a systematic theory to inform triage implementation was developed. This paper describes the extension of this approach to scale-up the triage program implementation in six additional hospitals. The scale-up is guided by a multi-level theory that extends the facility level theory to include cross-facility learning networks and oversight by the health system. We explain the process of theory development to implement interventions and demonstrate how these require the combination of local contextual knowledge with evidence from the implementation science literature. We also describe our approach for evaluating the theory to assess its effectiveness in achieving key implementation outcomes. This paper provides an example of how to use implementation theories to guide the development and evaluation of complex programs in real-world settings.

Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff.

BACKGROUND: Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability. OBJECTIVE: To investigate and describe the experiences of early adopters and explorers of Medicare's CoCM codes. DESIGN AND PARTICIPANTS: Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff. APPROACH: A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team. KEY RESULTS: Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes. CONCLUSIONS: With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.

Evidence-based Operations Management in Health Information Management: A Case Study.

This is a case study of the evidence-based management practices of a centralized health information management (HIM) department in a large integrated healthcare delivery system. The case study used interviews and focus groups, as well as de-identified dashboards, to explore the impact of reporting on the organization. The dashboards and key performance indicators (KPIs) were initially developed in 2012 and have continued to evolve. The themes that resulted include the following: (1) evidence-based management is integral to the culture of the organization; (2) communicating regularly via dashboards and KPIs is key to transmitting the value of HIM to the entire organization; and (3) staff not only report the required measures for the dashboard but also take pride in it and often develop methods for tracking their individual performance. Most evidence supporting HIM operations management is related to coding and clinical documentation improvement, but even in those areas, national benchmarks are missing. It is important for the HIM profession to develop national and regional benchmarks to assist professionals in managing operations effectively and communicating their value to the healthcare industry.

A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program.

BACKGROUND: Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community. METHODS: The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program. RESULTS: Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions. CONCLUSIONS: Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.

The impact of inter-organizational alignment (IOA) on implementation outcomes: evaluating unique and shared organizational influences in education sector mental health.

BACKGROUND: Integrated healthcare delivered by work groups in nontraditional service settings is increasingly common, yet contemporary implementation frameworks typically assume a single organization-or organizational unit-within which system-level processes influence service quality and implementation success. Recent implementation frameworks predict that inter-organizational alignment (i.e., similarity in values, characteristics, activities related to implementation across organizations) may facilitate the implementation of evidence-based practices (EBP), but few studies have evaluated this premise. This study's aims examine the impact of overlapping organizational contexts by evaluating the implementation contexts of externally employed mental health clinicians working in schools-the most common integrated service delivery setting for children and adolescents. Aim 1 is to estimate the effects of unique intra-organizational implementation contexts and combined inter-organizational alignment on implementation outcomes. Aim 2 is to examine the underlying mechanisms through which inter-organizational alignment facilitates or hinders EBP implementation. METHODS/DESIGN: This study will conduct sequential, exploratory mixed-methods research to evaluate the intra- and inter-organizational implementation contexts of schools and the external community-based organizations that most often employ school-based mental health clinicians, as they relate to mental health EBP implementation. Aim 1 will involve quantitative surveys with school-based, externally-employed mental health clinicians, their supervisors, and proximal school-employed staff (total n = 120 participants) to estimate the effects of each organization's general and implementation-specific organizational factors (e.g., climate, leadership) on implementation outcomes (fidelity, acceptability, appropriateness) and assess the moderating role of the degree of clinician embeddedness in the school setting. Aim 2 will explore the mechanisms through which inter-organizational alignment influences implementation outcomes by presenting the results of Aim 1 surveys to school-based clinicians (n = 30) and conducting semi-structured qualitative interviews. Qualitative data will be evaluated using an integrative inductive and deductive approach. DISCUSSION: The study aims are expected to identify intra- and inter-organizational constructs that are most instrumental to EBP implementation success in school-based integrated care settings and illuminate mechanisms that may account for the influence of inter-organizational alignment. In addition to improving school-based mental health, these findings will spur future implementation science that considers the relationships across organizations and optimize the capacity of implementation science to guide practice in increasingly complex systems of care.

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care.

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices.

Behavioral Health Integration in Large Multi-group Pediatric Practice.

There is increasing interest in methods to improve access to behavioral health services for children and adolescents. Children's Community Pediatric Behavioral Health Service (CCPBHS) is an integrated behavioral health service whose method of (a) creating a leadership team with empowered administrative and clinical stakeholders who can act on a commitment to change and (b) having a clear mission statement with integrated administrative and clinical care processes can serve as a model for implementing integration efforts within the medical home. Community Pediatrics Behavioral Health Service (CPBHS) is a sustainable initiative that improved the utilization of physical health and behavioral health systems for youth and improved the utilization of evidence-based interventions for youth served in primary care.

The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease.

OBJECTIVE: To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites. METHODS: Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals. RESULTS: The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiative's evidence-base and methods for others to replicate our work. CONCLUSIONS: The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making.

Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.

Animal-Assisted Therapy in Pediatric Palliative Care.

Animal-assisted therapy is an emerging complementary strategy with an increasing presence in the literature. Limited studies have been conducted with children, particularly those with life-threatening and life-limiting conditions. Although outcomes show promise in decreasing suffering of children receiving palliative care services, more work is needed to validate evidence to support implementation of animal-assisted therapy with this vulnerable population.

Are we talking the same paradigm? Considering methodological choices in health education systematic review.

For the past two decades, there have been calls for medical education to become more evidence-based. Whilst previous works have described how to use such methods, there are no works discussing when or why to select different methods from either a conceptual or pragmatic perspective. This question is not to suggest the superiority of such methods, but that having a clear rationale to underpin such choices is key and should be communicated to the reader of such works. Our goal within this manuscript is to consider the philosophical alignment of these different review and synthesis modalities and how this impacts on their suitability to answer different systematic review questions within health education. The key characteristic of a systematic review that should impact the synthesis choice is discussed in detail. By clearly defining this and the related outcome expected from the review and for educators who will receive this outcome, the alignment will become apparent. This will then allow deployment of an appropriate methodology that is fit for purpose and will indeed justify the significant work needed to complete a systematic. Key items discussed are the positivist synthesis methods meta-analysis and content analysis to address questions in the form of 'whether and what' education is effective. These can be juxtaposed with the constructivist aligned thematic analysis and meta-ethnography to address questions in the form of 'why'. The concept of the realist review is also considered. It is proposed that authors of such work should describe their research alignment and the link between question, alignment and evidence synthesis method selected. The process of exploring the range of modalities and their alignment highlights gaps in the researcher's arsenal. Future works are needed to explore the impact of such changes in writing from authors of medical education systematic review.

Outcomes of Clinical Nurse Specialist Role Transformation to Population-Focused Model.

PURPOSE/OBJECTIVES: In 2010, our comprehensive cancer center developed a professional practice model where the clinical nurse specialist role was transformed to proactively plan and facilitate evidence-based best practices in collaboration with a transdisciplinary, population-focused team that manages the patient across the cancer care continuum. BACKGROUND: Prior to this transition, practice was unit based, focused on nursing staff education, skills, and competencies, and practice varied widely based on the needs of the unit. This lack of role consistency resulted in decreased autonomy and collaboration and frustration with not consistently impacting positive outcomes. DESCRIPTION: Nursing leadership worked with the clinical nurse specialists to develop and transition to a population-focused model. Some responsibilities in the unit-based model were retained, whereas others were transitioned to different roles. The reporting structure was centralized, and the role was realigned to focus on a specific patient population encompassing care from diagnosis throughout survivorship. OUTCOME: Baseline job satisfaction data were collected prior to the transition and repeated at 6 and 12 months, then 2, 3, and 4 years after implementation. Over time, there was significant improvement in participation in decision making, support of leadership, and positive contributions to patients and staff, resulting in improved nursing-sensitive patient outcomes, an increase in evidence-based practice initiatives and nursing research projects, and substantial professional growth of clinical staff. CONCLUSION: With this practice model, clinical nurse specialists consistently and proactively plan and facilitate evidence-based best practice in collaboration with a transdisciplinary team that manages the patient from diagnosis through the cancer trajectory. Results of outcome measurement report job satisfaction at an all-time high. Significant impact is demonstrated for patients and families, the nursing staff, and the organization. IMPLICATIONS: Healthcare organizations should evaluate current roles and practice models for opportunities to incorporate innovations that will result in improved patient care and satisfaction.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION: Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders. METHODS: We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness. RESULTS: We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities. CONCLUSIONS: Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

Evidence-informed person-centred health care (part II): are 'cognitive biases plus' underlying the EBM paradigm responsible for undermining the quality of evidence?

INTRODUCTION: Recently, some leaders of the evidence-based medicine (EBM) movement drew attention to the "unintended" negative consequences associated with EBM. The term 'cognitive biases plus' was introduced in part I to encompass cognitive biases, conflicts of interests, fallacies and certain behaviours. HYPOTHESIS: 'Cognitive biases plus' in those closely involved in creating and promoting the EBM paradigm are responsible for their (1) inability to anticipate and then recognize flaws in the tenets of EBM; (2) discounting alternative views; and (3) delaying reform. METHODS: A narrative review style was used, with methods as in part I. APPRAISAL OF LITERATURE: Over the past two decades there has been mounting qualitative and quantitative methodological evidence to suggest that the faith placed in (1) the EBM hierarchy with randomized controlled trials and systematic reviews at the summit; (2) the reliability of biostatistical methods to quantitate data; and (3) the primacy of sources of pre-appraised evidence, is seriously misplaced. Consequently, the evidence that informs person-centred care is compromised. DISCUSSION: Arguments focusing on 'cognitive biases plus' are offered to support our hypothesis. To the best of our knowledge, EBM proponents have not provided an explanation. CONCLUSIONS: Reform is urgently needed to minimize continuing risks to patients. If our hypothesis is correct, then in addition to the suggestions made in part I, deficiencies in the paradigm must be corrected. Meaningful solutions are only possible if the biases of scientific inbreeding and groupthink are minimized by collaboration between EBM leaders and those who have been sounding warning bells.

Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP.

BACKGROUND: Making evidence-based practice (EBP) a reality throughout an organization is a challenging goal in healthcare services. Leadership has been recognized as a critical element in that process. However, little is known about the exact role and function of various levels of leadership in the successful institutionalization of EBP within an organization. AIMS: To uncover what leaders at different levels and in different roles actually do, and what actions they take to develop, enhance, and sustain EBP as the norm. METHODS: Qualitative data from a case study regarding institutionalization of EBP in two contrasting cases (Role Model and Beginner hospitals) were systematically analyzed. Data were obtained from multiple interviews of leaders, both formal and informal, and from staff nurse focus groups. A deductive coding schema, based on concepts of functional leadership, was developed for this in-depth analysis. RESULTS: Participants' descriptions reflected a hierarchical array of strategic, functional, and cross-cutting behaviors. Within these macrolevel "themes," 10 behavioral midlevel themes were identified; for example, Intervening and Role modeling. Each theme is distinctive, yet various themes and their subthemes were interrelated and synergistic. These behaviors and their interrelationships were conceptualized in the framework "Leadership Behaviors Supportive of EBP Institutionalization" (L-EBP). Leaders at multiple levels in the Role Model case, both formal and informal, engaged in most of these behaviors. LINKING EVIDENCE TO ACTION: Supportive leadership behaviors required for organizational institutionalization of EBP reflect a complex set of interactive, multifaceted EBP-focused actions carried out by leaders from the chief nursing officer to staff nurses. A related framework such as L-EBP may provide concrete guidance needed to underpin the often-noted but abstract finding that leaders should "support" EBP.