Clinician and health service interventions to reduce the greenhouse gas emissions generated by healthcare: a systematic review.

OBJECTIVE: To synthesise the available evidence on the effects of interventions designed to improve the delivery of healthcare that reduces the greenhouse gas (GHG) emissions of healthcare. DESIGN: Systematic review and structured synthesis. SEARCH SOURCES: Cochrane Central Register of Controlled Trials, PubMed, Web of Science and Embase from inception to 3 May 2023. SELECTION CRITERIA: Randomised, quasi-randomised and non-randomised controlled trials, interrupted time series and controlled or uncontrolled before-after studies that assessed interventions primarily designed to improve the delivery of healthcare that reduces the GHG emissions of healthcare initiated by clinicians or healthcare services within any setting. MAIN OUTCOME MEASURES: Primary outcome was GHG emissions. Secondary outcomes were financial costs, effectiveness, harms, patient-relevant outcomes, engagement and acceptability. DATA COLLECTION AND ANALYSIS: Paired authors independently selected studies for inclusion, extracted data, and assessed risk of bias using a modified checklist for observational studies and the certainty of the evidence using Grades of Recommendation, Assessment, Development and Evaluation. Data could not be pooled because of clinical and methodological heterogeneity, so we synthesised results in a structured summary of intervention effects with vote counting based on direction of effect. RESULTS: 21 observational studies were included. Interventions targeted delivery of anaesthesia (12 of 21), waste/recycling (5 of 21), unnecessary test requests (3 of 21) and energy (1 of 21). The primary intervention type was clinician education. Most (20 of 21) studies were judged at unclear or high risk of bias for at least one criterion. Most studies reported effect estimates favouring the intervention (GHG emissions 17 of 18, costs 13 of 15, effectiveness 18 of 20, harms 1 of 1 and staff acceptability 1 of 1 studies), but the evidence is very uncertain for all outcomes (downgraded predominantly for observational study design and risk of bias). No studies reported patient-relevant outcomes other than death or engagement with the intervention. CONCLUSIONS: Interventions designed to improve the delivery of healthcare that reduces GHG emissions may reduce GHG emissions and costs, reduce anaesthesia use, waste and unnecessary testing, be acceptable to staff and have little to no effect on energy use or unintended harms, but the evidence is very uncertain. Rigorous studies that measure GHG emissions using gold-standard life cycle assessment are needed as well as studies in more diverse areas of healthcare. It is also important that future interventions to reduce GHG emissions evaluate the effect on beneficial and harmful patient outcomes. PROSPERO REGISTRATION NUMBER: CRD42022309428.

Referral Patterns for People With Musculoskeletal Complaints in General Practice: An Analysis From an Australian Primary Care Database.

OBJECTIVE: Our objective was to examine referral patterns for people with musculoskeletal complaints presenting to Australian general practitioners (GPs). METHODS: This longitudinal analysis from the Population Level Analysis Reporting (POLAR) database includes 133,279 patients with low back (≥18 years old) or neck, shoulder, and/or knee (≥45 years old) complaints seen by 4,538 GPs across 269 practices from 2014 through 2018. Referrals to allied health and medical and/or surgical specialists were included. We determined the number of patients with referrals and GPs who made referrals and examined their timing, associations, and trends over time. RESULTS: A total of 43,666 patients (33%) received and 3,053 GPs (67%) made at least one referral. Most referrals were to allied health (n = 25,830, 19%), followed by surgeons (n = 18,805, 14%). Surgical referrals were higher for knee complaints (n = 6,140, 24%) compared with low back, neck, and shoulder complaints (range 8%-15%). The referral category varied predominantly by body region followed by gender, socioeconomic status, and primary health network. Time to allied health referral ranged between median (interquartile range [IQR]) 14 days (0-125 days) for neck complaints and 56 days (5-177 days) for knee complaints. Surgical referrals occurred sooner for those with knee complaints (15 days, IQR 0-128 days). There was a 2.2% (95% confidence interval [CI] 1.9%-2.4%) annual increase in the proportion of allied health referrals and a 1.9% (95% CI 1.6%-2.1%) decrease in surgical referrals across all sites. CONCLUSION: One-third of patients receive, and two-thirds of GPs make, referrals for musculoskeletal complaints. Understanding the reasons for referral and differences between GPs who refer more and less frequently may identify factors that explain variations in practice.

Health facility availability and readiness for family planning and maternity and neonatal care services in Nepal: Analysis of cross-sectional survey data.

OBJECTIVES: To determine the availability and readiness of health facilities to provide family planning, antenatal care and basic emergency obstetric and newborn care in Nepal in 2021. Secondary objectives were to identify progress since 2015 and factors associated with readiness. METHOD: This is a secondary analysis of cross-sectional Nepal Health Facility Survey (NHFS) data collected in 2015 and 2021. The main outcome measures were availability and readiness of family planning, antenatal care, and basic emergency obstetric and newborn care services. Readiness indices were calculated using WHO-recommended service availability and readiness assessment (SARA) methods (score range 0 to 100%, with 100% indicating facilities are fully prepared to provide a specific service). We used independent t-tests to compare readiness indices in 2015 and 2021. Factors potentially associated with readiness (rurality setting, ecological region, managing authority, management meeting, quality assurance activities, and external supervision) were explored using multivariable linear regression. RESULTS: There were 940 and 1565 eligible health facilities in the 2015 and 2021 surveys, respectively. Nearly all health facilities provided family planning (2015: n = 919 (97.8%); 2021: n = 1530 (97.8%)) and antenatal care services (2015: n = 920 (97.8%); 2021: n = 1538 (98.3%)) in both years, but only half provided delivery services (2015: n = 457 (48.6%); 2021: n = 804 (51.4%)). There were suboptimal improvements in readiness indices over time: (2015-21: family planning 68.0% to 70.9%, p<0.001, antenatal care 49.5% to 54.1%, p<0.001 and basic emergency obstetric and newborn care 56.7% to 58.0%, p = 0.115). The regression model comprising combined datasets of both NHFSs indicates facilities with regular management meetings and/or quality assurance activities had significantly greater readiness for all three indices. Similarly, public facilities had greater readiness for family planning and basic emergency obstetric and newborn care while they had lower readiness for antenatal care. CONCLUSIONS: Readiness to deliver family planning, antenatal care and basic emergency obstetric and newborn care services in Nepal remains inadequate, with little improvement observed over six years.

Patterns of Imaging Requests By General Practitioners for People With Musculoskeletal Complaints: An Analysis From a Primary Care Database.

OBJECTIVE: The aim of this study was to examine imaging requested by general practitioners (GPs) for patients with low back, neck, shoulder, and knee complaints over 5 years (2014-2018). METHODS: This analysis from the Australian Population Level Analysis and Reporting database included patients presenting with a diagnosis of low back, neck, shoulder, and/or knee complaints. Eligible imaging requests included low back and neck x-ray, computed tomography (CT), and magnetic resonance imaging (MRI); knee x-ray, CT, MRI, and ultrasound; and shoulder x-ray, MRI, and ultrasound. We determined number of imaging requests and examined their timing, associated factors, and trends over time. Primary analysis included imaging requests from 2 weeks before diagnosis to 1 year after diagnosis. RESULTS: There were 133,279 patients (57% low back, 25% knee, 20% shoulder, and 11% neck complaints). Imaging was most common among those with a shoulder (49%) complaint, followed by knee (43%), neck (34%), and low back complaints (26%). Most requests occurred simultaneously with the diagnosis. Imaging modality varied by body region and, to a lesser extent, by gender, socioeconomic status, and primary health network. For low back, there was a 1.3% (95% confidence interval [95% CI] 1.0-1.6) annual increase in proportion of MRI and a concomitant 1.3% (95% CI 0.8-1.8) decrease in CT requests. For neck, there was a 3.0% (95% CI 2.1-3.9) annual increase in proportion of MRI and a concomitant 3.1% (95% CI 2.2-4.0) decrease in x-ray requests. CONCLUSION: GPs commonly request early diagnostic imaging for musculoskeletal complaints at odds with recommended practice. We observed a trend towards more complex imaging for neck and back complaints.

Evaluating an audit and feedback intervention for reducing overuse of pathology test requesting by Australian general practitioners: protocol for a factorial cluster randomised controlled trial.

INTRODUCTION: Consistent evidence shows pathology services are overused worldwide and that about one-third of testing is unnecessary. Audit and feedback (AF) is effective for improving care but few trials evaluating AF to reduce pathology test requesting in primary care have been conducted. The aim of this trial is to estimate the effectiveness of AF for reducing requests for commonly overused pathology test combinations by high-requesting Australian general practitioners (GPs) compared with no intervention control. A secondary aim is to evaluate which forms of AF are most effective. METHODS AND ANALYSIS: This is a factorial cluster randomised trial conducted in Australian general practice. It uses routinely collected Medicare Benefits Schedule data to identify the study population, apply eligibility criteria, generate the interventions and analyse outcomes. On 12 May 2022, all eligible GPs were simultaneously randomised to either no intervention control or to one of eight intervention groups. GPs allocated to an intervention group received individualised AF on their rate of requesting of pathology test combinations compared with their GP peers. Three separate elements of the AF intervention will be evaluated when outcome data become available on 11 August 2023: (1) invitation to participate in continuing professional development-accredited education on appropriate pathology requesting, (2) provision of cost information on pathology test combinations and (3) format of feedback. The primary outcome is the overall rate of requesting of any of the displayed combinations of pathology tests of GPs over 6 months following intervention delivery. With 3371 clusters, assuming no interaction and similar effects for each intervention, we anticipate over 95% power to detect a difference of 4.4 requests in the mean rate of pathology test combination requests between the control and intervention groups. ETHICS AND DISSEMINATION: Ethics approval was received from the Bond University Human Research Ethics Committee (#JH03507; approved 30 November 2021). The results of this study will be published in a peer-reviewed journal and presented at conferences. Reporting will adhere to Consolidated Standards of Reporting Trials. TRIAL REGISTRATION NUMBER: ACTRN12622000566730.

Which clinical research questions are the most important? Development and preliminary validation of the Australia & New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network Research Question Importance Tool (ANZMUSC-RQIT).

BACKGROUND AND AIMS: High quality clinical research that addresses important questions requires significant resources. In resource-constrained environments, projects will therefore need to be prioritized. The Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network aimed to develop a stakeholder-based, transparent, easily implementable tool that provides a score for the 'importance' of a research question which could be used to rank research projects in order of importance. METHODS: Using a mixed-methods, multi-stage approach that included a Delphi survey, consensus workshop, inter-rater reliability testing, validity testing and calibration using a discrete-choice methodology, the Research Question Importance Tool (ANZMUSC-RQIT) was developed. The tool incorporated broad stakeholder opinion, including consumers, at each stage and is designed for scoring by committee consensus. RESULTS: The ANZMUSC-RQIT tool consists of 5 dimensions (compared to 6 dimensions for an earlier version of RQIT): (1) extent of stakeholder consensus, (2) social burden of health condition, (3) patient burden of health condition, (4) anticipated effectiveness of proposed intervention, and (5) extent to which health equity is addressed by the research. Each dimension is assessed by defining ordered levels of a relevant attribute and by assigning a score to each level. The scores for the dimensions are then summed to obtain an overall ANZMUSC-RQIT score, which represents the importance of the research question. The result is a score on an interval scale with an arbitrary unit, ranging from 0 (minimal importance) to 1000. The ANZMUSC-RQIT dimensions can be reliably ordered by committee consensus (ICC 0.73-0.93) and the overall score is positively associated with citation count (standardised regression coefficient 0.33, p<0.001) and journal impact factor group (OR 6.78, 95% CI 3.17 to 14.50 for 3rd tertile compared to 1st tertile of ANZMUSC-RQIT scores) for 200 published musculoskeletal clinical trials. CONCLUSION: We propose that the ANZMUSC-RQIT is a useful tool for prioritising the importance of a research question.

Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial.

Importance: Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. Objective: To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). Design, Setting, and Participants: This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. Interventions: Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. Main Outcomes and Measures: The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. Results: A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). Conclusions and Relevance: Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. Trial Registration: ANZCTR Identifier: ACTRN12619001503112.

Factors influencing clinician prescribing of disease-modifying anti-rheumatic drugs for inflammatory arthritis: A systematic review and thematic synthesis of qualitative studies.

Understanding factors that influence prescribing of disease-modifying anti-rheumatic drugs (DMARDs) will inform strategies to optimise care of people with inflammatory arthritis. We performed a systematic review and thematic synthesis of qualitative studies to explore these factors. Inclusion criteria were: use of qualitative or mixed methods; rheumatologist, nurse or pharmacist perspectives; prescription of any DMARD (conventional [cs], targeted synthetic [ts], biologic [b], biosimilars) and/or glucocorticoids; in any healthcare setting in any country. MEDLINE, Embase and EBSCOhost CINAHL Plus were searched from inception to 15 June 2021. Pairs of review authors independently identified studies for inclusion, assessed methodological quality using the Critical Appraisal Skills Programme checklist, and extracted and thematically synthesised data. Confidence in synthesis themes was evaluated using the GRADE Confidence in Evidence from Reviews of Qualitative research (CERQual) approach. We included 15 studies involving 716 clinicians (683 rheumatologists, 27 nurses, 6 pharmacists) across 10 countries, all focusing on management of patients with rheumatoid arthritis (RA). Six themes were identified: Rheumatologist prescribing is influenced by patients' characteristics, preferences, symptoms and negative responses to medication; Rheumatologist knowledge, experience, habits and subjective judgements are strong drivers of prescribing behaviour; High demands on consultation time impede shared decision-making; Costs and complexity of medication funding arrangements limit prescribing options; Clinicians recognise the importance of providing patient education about medication options; and Clinicians value colleagues' opinions and support to inform prescribing decisions. The majority of themes were graded as moderate confidence (n  =  4), reflecting they are likely to reasonably represent the factors influencing prescribing of DMARDs to people with RA. Quality improvement strategies that address these factors are likely to support best practice pharmacologic management of RA and may be potentially applicable to other types of inflammatory arthritis. High demand on consultation time and complexity of medication funding arrangements are system factors that may or may not be amenable to change. Easily accessible living national guidelines which include lay summaries and treatment algorithms to support prescribing decisions may address some of the themes.

Improving adherence to acute low back pain guideline recommendations with chiropractors and physiotherapists: the ALIGN cluster randomised controlled trial.

BACKGROUND: Acute low back pain is a common condition, has high burden, and there are evidence-to-practice gaps in the chiropractic and physiotherapy setting for imaging and giving advice to stay active. The aim of this cluster randomised trial was to estimate the effects of a theory- and evidence-based implementation intervention to increase chiropractors' and physiotherapists' adherence to a guideline for acute low back pain compared with the comparator (passive dissemination of the guideline). In particular, the primary aim of the intervention was to reduce inappropriate imaging referral and improve patient low back pain outcomes, and to determine whether this intervention was cost-effective. METHODS: Physiotherapy and chiropractic practices in the state of Victoria, Australia, comprising at least one practising clinician who provided care to patients with acute low back pain, were invited to participate. Patients attending these practices were included if they had acute non-specific low back pain (duration less than 3 months), were 18 years of age or older, and were able to understand and read English. Practices were randomly assigned either to a tailored, multi-faceted intervention based on the guideline (interactive educational symposium plus academic detailing) or passive dissemination of the guideline (comparator). A statistician independent of the study team undertook stratified randomisation using computer-generated random numbers; four strata were defined by professional group and the rural or metropolitan location of the practice. Investigators not involved in intervention delivery were blinded to allocation. Primary outcomes were X-ray referral self-reported by clinicians using a checklist and patient low back pain-specific disability (at 3 months). RESULTS: A total of 104 practices (43 chiropractors, 85 physiotherapists; 755 patients) were assigned to the intervention and 106 practices (45 chiropractors, 97 physiotherapists; 603 patients) to the comparator; 449 patients were available for the patient-level primary outcome. There was no important difference in the odds of patients being referred for X-ray (adjusted (Adj) OR: 1.40; 95% CI 0.51, 3.87; Adj risk difference (RD): 0.01; 95% CI - 0.02, 0.04) or patient low back pain-specific disability (Adj mean difference: 0.37; 95% CI - 0.48, 1.21, scale 0-24). The intervention did lead to improvement for some key secondary outcomes, including giving advice to stay active (Adj OR: 1.96; 95% CI 1.20, 3.22; Adj RD: 0.10; 95% CI 0.01, 0.19) and intending to adhere to the guideline recommendations (e.g. intention to refer for X-ray: Adj OR: 0.27; 95% CI 0.17, 0.44; intention to give advice to stay active: Adj OR: 2.37; 95% CI 1.51, 3.74). CONCLUSIONS: Intervention group clinicians were more likely to give advice to stay active and to intend to adhere to the guideline recommendations about X-ray referral. The intervention did not change the primary study outcomes, with no important differences in X-ray referral and patient disability between groups, implying that hypothesised reductions in health service utilisation and/or productivity gains are unlikely to offset the direct costs of the intervention. We report these results with the caveat that we enrolled less patients into the trial than our determined sample size. We cannot recommend this intervention as a cost-effective use of resources. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609001022257 . Retrospectively registered on 25 November 2009.

Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: a systematic review with qualitative evidence synthesis using the Theoretical Domains Framework.

BACKGROUND: Understanding barriers and enablers to monitoring and deprescribing opioids will enable the development of tailored interventions to improve both practices. OBJECTIVE: To perform a qualitative evidence synthesis of the barriers and enablers to monitoring ongoing appropriateness and deprescribing of opioids for chronic non-cancer pain (CNCP) and to map the findings to the Theoretical Domains Framework (TDF). METHODS: We included English-language qualitative studies that explored healthcare professional (HCP), patient, carer and the general public's perceptions regarding monitoring and deprescribing opioids for CNCP. We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO from inception to August 2020. Two authors independently selected the studies, extracted the data, assessed the methodological quality using the Critical Appraisal Skills Programme, and assessed the confidence in the findings using GRADE CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research). We used an inductive approach to synthesis of qualitative data and mapped identified themes to TDF domains. RESULTS: From 6948 records identified we included 21 studies, involving 209 HCPs and 330 patients. No studies involved carers or the general public. Five barrier themes were identified: limited alternatives to opioids, management of pain is top priority, patient understanding, expectations and experiences, prescriber pressures, and reluctance to change. Four enabler themes were identified: negative effects of opioids and benefits of deprescribing, clear communication and expectations for deprescribing, support for patients, and support for prescribers. 16 barrier and 12 enabler subthemes were identified; most were graded as high (n=15) or moderate (n=9) confidence. The TDF domains 'beliefs about consequences', 'environmental context and resources', 'social influences' and 'emotion' were salient for patients and HCPs. The domains 'skills' and 'beliefs about capabilities' were more salient for HCPs. CONCLUSION: Future implementation interventions aimed at monitoring and deprescribing opioids should target the patient and HCP barriers and enablers identified in this synthesis. PROSPERO REGISTRATION NUMBER: CRD42019140784.

Unpacking the behavioural components and delivery features of early childhood obesity prevention interventions in the TOPCHILD Collaboration: a systematic review and intervention coding protocol.

INTRODUCTION: Little is known about how early (eg, commencing antenatally or in the first 12 months after birth) obesity prevention interventions seek to change behaviour and which components are or are not effective. This study aims to (1) characterise early obesity prevention interventions in terms of target behaviours, delivery features and behaviour change techniques (BCTs), (2) explore similarities and differences in BCTs used to target behaviours and (3) explore effectiveness of intervention components in preventing childhood obesity. METHODS AND ANALYSIS: Annual comprehensive systematic searches will be performed in Epub Ahead of Print/MEDLINE, Embase, Cochrane (CENTRAL), CINAHL, PsycINFO, as well as clinical trial registries. Eligible randomised controlled trials of behavioural interventions to prevent childhood obesity commencing antenatally or in the first year after birth will be invited to join the Transforming Obesity in CHILDren Collaboration. Standard ontologies will be used to code target behaviours, delivery features and BCTs in both published and unpublished intervention materials provided by trialists. Narrative syntheses will be performed to summarise intervention components and compare applied BCTs by types of target behaviours. Exploratory analyses will be undertaken to assess effectiveness of intervention components. ETHICS AND DISSEMINATION: The study has been approved by The University of Sydney Human Research Ethics Committee (project no. 2020/273) and Flinders University Social and Behavioural Research Ethics Committee (project no. HREC CIA2133-1). The study's findings will be disseminated through peer-reviewed publications, conference presentations and targeted communication with key stakeholders. PROSPERO REGISTRATION NUMBER: CRD42020177408.

Transforming Obesity Prevention for CHILDren (TOPCHILD) Collaboration: protocol for a systematic review with individual participant data meta-analysis of behavioural interventions for the prevention of early childhood obesity.

INTRODUCTION: Behavioural interventions in early life appear to show some effect in reducing childhood overweight and obesity. However, uncertainty remains regarding their overall effectiveness, and whether effectiveness differs among key subgroups. These evidence gaps have prompted an increase in very early childhood obesity prevention trials worldwide. Combining the individual participant data (IPD) from these trials will enhance statistical power to determine overall effectiveness and enable examination of individual and trial-level subgroups. We present a protocol for a systematic review with IPD meta-analysis to evaluate the effectiveness of obesity prevention interventions commencing antenatally or in the first year after birth, and to explore whether there are differential effects among key subgroups. METHODS AND ANALYSIS: Systematic searches of Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo and trial registries for all ongoing and completed randomised controlled trials evaluating behavioural interventions for the prevention of early childhood obesity have been completed up to March 2021 and will be updated annually to include additional trials. Eligible trialists will be asked to share their IPD; if unavailable, aggregate data will be used where possible. An IPD meta-analysis and a nested prospective meta-analysis will be performed using methodologies recommended by the Cochrane Collaboration. The primary outcome will be body mass index z-score at age 24±6 months using WHO Growth Standards, and effect differences will be explored among prespecified individual and trial-level subgroups. Secondary outcomes include other child weight-related measures, infant feeding, dietary intake, physical activity, sedentary behaviours, sleep, parenting measures and adverse events. ETHICS AND DISSEMINATION: Approved by The University of Sydney Human Research Ethics Committee (2020/273) and Flinders University Social and Behavioural Research Ethics Committee (HREC CIA2133-1). Results will be relevant to clinicians, child health services, researchers, policy-makers and families, and will be disseminated via publications, presentations and media releases. PROSPERO REGISTRATION NUMBER: CRD42020177408.

What is "usual care" in the rehabilitation of upper limb sensory loss after stroke? Results from a national audit and knowledge translation study.

PURPOSE: To characterise the assessments and treatments that comprise "usual care" for stroke patients with somatosensory loss, and whether usual care has changed over time. MATERIALS AND METHODS: Comparison of cross-sectional, observational data from (1) Stroke Foundation National Audit of Acute (2007-2019) and Rehabilitation (2010-2018) Stroke Services and (2) the SENSe Implement multi-site knowledge translation study with occupational therapists and physiotherapists (n = 115). Descriptive statistics, random effects logistic regression, and content analysis were used. RESULTS: Acute hospitals (n = 172) contributed 24 996 cases across audits from 2007 to 2019 (median patient age 76 years, 54% male). Rehabilitation services (n = 134) contributed organisational survey data from 2010 to 2014, with 7165 cases (median 76 years, 55% male) across 2016-2018 clinical audits (n = 127 services). Somatoensory assessment protocol use increased from 53% (2007) to 86% (2019) (odds ratio 11.4, 95% CI 5.0-25.6). Reported use of sensory-specific retraining remained stable over time (90-93%). Therapist practice reports for n = 86 patients with somatosensory loss revealed 16% did not receive somatosensory rehabilitation. The most common treatment approaches were sensory rehabilitation using everyday activities (69%), sensory re-education (68%), and compensatory strategies (64%). CONCLUSION: Sensory assessment protocol use has increased over time while sensory-specific training has remained stable. Sensory rehabilitation in the context of everyday activities is a common treatment approach. Clinical trial registration number: ACTRN12615000933550IMPLICATIONS FOR REHABILITATIONOnly a small proportion of upper limb assessments conducted with stroke patients focus specifically on sensation; increased use of standardised upper limb assessments for sensory loss is needed.Stroke patients assessed as having upper limb sensory loss frequently do not receive treatment for their deficits.Therapists typically use everyday activities to treat upper limb sensory loss and may require upskilling in sensory-specific retraining to benefit patients.

Consumer understanding of terms used in imaging reports requested for low back pain: a cross-sectional survey.

OBJECTIVES: To investigate (1) self-reported societal comprehension of common and usually non-serious terms found in lumbar spine imaging reports and (2) its relationship to perceived seriousness, likely persistence of low back pain (LBP), fear of movement, back beliefs and history and intensity of LBP. DESIGN: Cross-sectional online survey of the general public. SETTING: Five English-speaking countries: UK, USA, Canada, New Zealand and Australia. PARTICIPANTS: Adults (age >18 years) with or without a history of LBP recruited in April 2019 with quotas for country, age and gender. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported understanding of 14 terms (annular fissure, disc bulge, disc degeneration, disc extrusion, disc height loss, disc protrusion, disc signal loss, facet joint degeneration, high intensity zone, mild canal stenosis, Modic changes, nerve root contact, spondylolisthesis and spondylosis) commonly found in lumbar spine imaging reports. For each term, we also elicited worry about its seriousness, and whether its presence would indicate pain persistence and prompt fear of movement. RESULTS: From 774 responses, we included 677 (87.5%) with complete and valid responses. 577 (85%) participants had a current or past history of LBP of whom 251 (44%) had received lumbar spine imaging. Self-reported understanding of all terms was poor. At best, 235 (35%) reported understanding the term 'disc degeneration', while only 71 (10.5%) reported understanding the term 'Modic changes'. For all terms, a moderate to large proportion of participants (range 59%-71%), considered they indicated a serious back problem, that pain might persist (range 52%-71%) and they would be fearful of movement (range 42%-57%). CONCLUSION: Common and usually non-serious terms in lumbar spine imaging reports are poorly understood by the general population and may contribute to the burden of LBP. TRIAL REGISTRATION NUMBER: ACTRN12619000545167.

Patterns of care for people presenting to Australian general practice with musculoskeletal complaints based on routinely collected data: protocol for an observational cohort study using the Population Level Analysis and Reporting (POLAR) database.

INTRODUCTION: General practice is integral to the Australian healthcare system. Outcome Health's POpulation Level Analysis and Reporting (POLAR) database uses de-identified electronic health records to analyse general practice data in Australia. Previous studies using routinely collected health data for research have not consistently reported the codes and algorithms used to describe the population, exposures, interventions and outcomes in sufficient detail to allow replication. This paper reports a study protocol investigating patterns of care for people presenting with musculoskeletal conditions to general practice in Victoria, Australia. Its focus is on the systematic approach used to classify and select eligible records from the POLAR database to facilitate replication. This will be useful for other researchers using routinely collected health data for research. METHODS AND ANALYSIS: This is a retrospective cohort study. Patient-related data will be obtained through electronic health records from a subset of general practices across three primary health networks (PHN) in southeastern Victoria. Data for patients with a low back, neck, shoulder and/or knee condition and who received at least one general practitioner (GP) face-to-face consultation between 1 January 2014 and 31 December 2018 will be included. Data quality checks will be conducted to exclude patients with poor data recording and/or non-continuous follow-up. Relational data files with eligible and valid records will be merged to select the study cohort and the GP care received (consultations, imaging requests, prescriptions and referrals) between diagnosis and 31 December 2018. Number and characteristics of patients and GPs, and number, type and timing of imaging requests, prescriptions for pain relief and referrals to other health providers will be investigated. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Cabrini and Monash University Human Research Ethics Committees (Reference Numbers 02-21-01-19 and 16975, respectively). Study findings will be reported to Outcome Health, participating PHNs, disseminated in academic journals and presented in conferences.

Development of a patient decision aid on subacromial decompression surgery and rotator cuff repair surgery: an international mixed-methods study.

OBJECTIVE: To develop and user test a patient decision aid for people with subacromial pain syndrome that presents evidence-based information on the benefits and harms of subacromial decompression surgery and rotator cuff repair surgery. DESIGN: Mixed-methods study outlining the development of a patient decision aid. SETTING: We assembled a multidisciplinary steering group, and used existing decision aids and decision science to draft the decision aid. Participants were recruited through social media (not restricted by country nor setting), local hospitals and the authors' collaboration network. PARTICIPANTS: People with shoulder pain and health professionals who manage people with shoulder pain. PRIMARY AND SECONDARY OUTCOMES: We interviewed participants to gather feedback on the decision aid, assessed useability and acceptability (using qualitative and quantitative methods) and performed iterative cycles of redrafting the decision aid and reinterviewing participants as necessary. Interview data were analysed using thematic analysis. Quantitative data were summarised descriptively. RESULTS: We interviewed 26 health professionals (11 physiotherapists, 7 orthopaedic surgeons, 4 general practitioners, 3 chiropractors and 1 osteopath) and 14 people with shoulder pain. Most health professionals and people with shoulder pain rated all aspects of decision aid acceptability as adequate-to-excellent (eg, length, presentation, comprehensibility). Interviews highlighted agreement among health professionals and people with shoulder pain on most aspects of the decision aid (eg, treatment options, summary of benefits, harms and practical issues, questions to ask a health professional, graphics, formatting). However, some aspects of the decision aid elicited divergent views among health professionals (eg, causes and symptoms of shoulder pain, evidence on benefits and harms). CONCLUSION: This decision aid could be an acceptable and valuable tool for helping people with subacromial pain syndrome make informed treatment choices. A randomised controlled trial evaluating whether this decision aid reduces people's intentions to undergo shoulder surgery and facilitates informed treatment choices is underway.Trial registration number ACTRN12621000992808.

Clinical practice guidelines for the management of atraumatic shoulder conditions: protocol for a systematic review.

INTRODUCTION: Shoulder conditions are a major cause of morbidity in the general population. Many clinical practice guidelines (CPGs) for shoulder conditions have been developed. Their purpose is to provide evidence-based recommendations to assist clinicians in providing optimal care to maximise patient outcomes. The aim of this systematic review is to identify, appraise, and compare the content and quality of CPGs for atraumatic shoulder conditions. METHODS AND ANALYSIS: CPGs for atraumatic shoulder conditions will be included provided they make recommendations about diagnosis and/or management, are identified by their authors as a guideline and are consistent with the Appraisal of Guidelines for Research and Evaluation (AGREE) II definition of a guideline. A systematic search of electronic databases, online guideline repositories and the websites of relevant professional societies will be conducted to identify eligible CPGs. Search terms relating to shoulder conditions (eg, 'adhesive capsulitis', 'rotator cuff' and 'bursitis') will be combined with a validated search filter for CPGs. Pairs of independent reviewers will determine eligibility of CPGs identified by the search. Quality appraisal of included CPGs will be performed using the AGREE II instrument. Recommendations from each CPG and how they were determined will be extracted and compared across similar CPGs. Results from this systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review. The results from this study will be published in a peer-reviewed journal and disseminated to professional societies that publish shoulder CPGs, clinical policy groups, clinicians, researchers and consumers. PROSPERO REGISTRATION NUMBER: CRD42020182723.

Prioritising models of healthcare service delivery for a more sustainable health system: a Delphi study of Australian health policy, clinical practice and management, academic and consumer stakeholders.

Objectives Healthcare expenditure is growing at an unsustainable rate in developed countries. A recent scoping review identified several alternative healthcare delivery models with the potential to improve health system sustainability. Our objective was to obtain input and consensus from an expert Delphi panel about which alternative models they considered most promising for increasing value in healthcare delivery in Australia and to contribute to shaping a research agenda in the field. Methods The panel first reviewed a list of 84 models obtained through the preceding scoping review and contributed additional ideas in an open round. In a subsequent scoring round, the panel rated the priority of each model in terms of its potential to improve health care sustainability in Australia. Consensus was assumed when ≥50% of the panel rated a model as (very) high priority (consensus on high priority) or as not a priority or low priority (consensus on low priority). Results Eighty-two of 149 invited participants (55%) representing all Australian states/territories and wide expertise completed round one; 71 completed round two. Consensus on high priority was achieved for 59 alternative models; 14 were rated as (very) high priority by ≥70% of the panel. Top priorities included improving medical service provision in aged care facilities, providing single-point-access multidisciplinary care for people with chronic conditions and providing tailored early discharge and hospital at home instead of in-patient care. No consensus was reached on 47 models, but no model was deemed low priority. Conclusions Input from an expert stakeholder panel identified healthcare delivery models not previously synthesised in systematic reviews that are a priority to investigate. Strong consensus exists among stakeholders regarding which models require the most urgent attention in terms of (cost-)effectiveness research. These findings contribute to shaping a research agenda on healthcare delivery models and where stakeholder engagement in Australia is likely to be high. What is known about the topic? Healthcare expenditure is growing at an unsustainable rate in high-income countries worldwide. A recent scoping review of systematic reviews identified a substantial body of evidence about the effects of a wide range of models of healthcare service delivery that can inform health system improvements. Given the large number of systematic reviews available on numerous models of care, a method for gaining consensus on the models of highest priority for implementation (where evidence demonstrates this will lead to beneficial effects and resource savings) or for further research (where evidence about effects is uncertain) in the Australian context is warranted. What does this paper add? This paper describes a method for reaching consensus on high-priority alternative models of service delivery in Australia. Stakeholders with leadership roles in health policy and government organisations, hospital and primary care networks, academic institutions and consumer advocacy organisations were asked to identify and rate alternative models based on their knowledge of the healthcare system. We reached consensus among ≥70% of stakeholders that improving medical care in residential aged care facilities, providing single-point-access multidisciplinary care for patients with a range of chronic conditions and providing early discharge and hospital at home instead of in-patient stay for people with a range of conditions are of highest priority for further investigation. What are the implications for practitioners? Decision makers seeking to optimise the efficiency and sustainability of healthcare service delivery in Australia could consider the alternative models rated as high priority by the expert stakeholder panel in this Delphi study. These models reflect the most promising alternatives for increasing value in the delivery of health care in Australia based on stakeholders' knowledge of the health system. Although they indicate areas where stakeholder engagement is likely to be high, further research is needed to demonstrate the effectiveness and cost-effectiveness of some of these models.

Factors influencing allied health professionals' implementation of upper limb sensory rehabilitation for stroke survivors: a qualitative study to inform knowledge translation.

OBJECTIVES: Somatosensory loss is common after stroke with one-in-two individuals affected. Although clinical practice guidelines recommend providing somatosensory rehabilitation, this impairment often remains unassessed and untreated. To address the gap between guideline recommendations and clinical practice, this study sought to understand the factors influencing delivery of evidence-based upper limb sensory rehabilitation after stroke. DESIGN: Qualitative study involving focus groups and interviews. Data analysis used an inductive approach (thematic analysis) and deductive analysis using implementation theory (the Theoretical Domains Framework and Normalisation Process Theory). SETTING: Eight healthcare organisations in metropolitan and regional areas of Victoria and New South Wales, Australia. PARTICIPANTS: Eighty-seven rehabilitation therapists (79% occupational therapists and 21% physiotherapists) were purposively sampled and participated in a knowledge translation study with staggered recruitment from 2014 to 2018. RESULTS: Three types of factors influenced therapists' delivery of upper limb somatosensory rehabilitation: individual ('The uncertain, unskilled therapist'), patient ('Patient understanding and priorities') and organisational ('System pressures and resources'). Deductive analysis using implementation theory identified key determinants of practice change, such as opportunities to consolidate new skills, the anticipated benefits of upskilling as a therapy team and the work anticipated by therapists to incorporate a new somatosensory rehabilitation approach. CONCLUSIONS: Occupational therapists and physiotherapists hold valuable insights towards practice change in somatosensory rehabilitation from the 'frontline'. Therapists experience barriers to change including a lack of knowledge and skills, lack of resources and organisational pressures. Facilitators for change were identified, including social support and therapists' perceived legitimacy in using new somatosensory rehabilitation approaches. Results will inform the design of a tailored implementation strategy to increase the use of evidence-based somatosensory rehabilitation in Australia. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12615000933550).