Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy.

BACKGROUND: Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. OBJECTIVE: The goal of this study is to describe the use of standardized/simulated patient/person (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. DESIGN: We observed 12 clinicians' first-time experiences with six unique decision-making algorithms, developed previously using rigorous Delphi methods, for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain. Clinicians were paired with two SPs trained to portray individuals with one of the concerning behaviors addressed by the algorithms in a telehealth environment. The SP evaluations were followed by individual interviews, guided by the Consolidated Framework for Implementation Research (CFIR), with each of the clinician participants. PARTICIPANTS: Twelve primary care clinicians and 24 SPs in Western Pennsylvania. MAIN MEASUREMENT: The primary outcome was identifying likely facilitators for the successful implementation of the EBP using the SP methodology. Our secondary outcome was to assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. RESULTS: The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. CONCLUSIONS: SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients. SETTING: Zoom simulated patient evaluations.

Using Mobile and Remote Simulation as a Research Methodology for Health Care Delivery Research.

SUMMARY STATEMENT: Mobile and remote simulation can be used as a research methodology to collect data in simulated environments to answer research questions pertaining to health care delivery. This research methodology can exponentially increase the reachable target study participants and provide generalizable conclusions. Using a large-scale national study in the United States as an exemplar, this article outlines the technology and equipment required to conduct mobile and remote simulations for research purposes. The cost associated with using mobile and remote simulations as well as the advantages and challenges of using this research methodology are also discussed.

Models of care in secure services for people with intellectual and developmental disability: Implementing the Walkway to Wellness.

BACKGROUND: Changes to policy around inpatient services for people with intellectual and developmental disability (IDD) who offend, have led to a need for services to reconsider their models of care. This has led to calls for more tailored, patient-centred care models, with less reliance solely on offence-related treatment programmes which can be unsuitable for a growing proportion of patients with more complex cognitive and behavioural difficulties. In response, the Walkway to Wellness (W2W) was developed at one National Health Service Trust providing secure services to people with IDD, with the intention of delivering a more collaborative, co-produced and goal-oriented care model that was better understood by staff and patient stakeholders. AIMS: To evaluate the implementation of the W2W using Normalisation Process Theory (NPT), an evidence-based theoretical approach is used across a number of health settings. METHODS: Staff were invited to complete a short questionnaire, using the NPT informed Normalisation Measure Development questionnaire, at two time points along the implementation process. Patients were invited to complete a simplified questionnaire. Both groups were asked for their views on the W2W and the process of its implementation. RESULTS: Although the W2W was more familiar to staff at the second time point, scores on the four NPT constructs showed a trend for it being less embedded in practice, with significant results concerning the ongoing appraisal of the new model. Patient views were mixed; some saw the benefit of more goal-oriented processes, but others considered it an additional chore hindering their own perceived goals. CONCLUSION: Early involvement of all stakeholders is required to enhance the understanding of changes to models of care. Live feedback should be used to refine and revise the model to meet the needs of patients, carers and staff members.

Closing the Care Gap: Management of Alcohol Use Disorder in Patients with Alcohol-associated Liver Disease.

Alcohol-associated liver disease (ALD)-related morbidity and mortality are rising in the United States. Although effective medications and behavioral interventions are available for the treatment of patients with alcohol use disorder (AUD), patients with ALD are profoundly undertreated for AUD. This article reviews the management of AUD in patients with ALD, with a focus on appropriate screening and diagnosis, management of alcohol withdrawal syndrome, pharmacotherapy for AUD, alcohol biomarkers, and behavioral interventions. Expanding access to AUD treatment is imperative for improving health outcomes in patients with ALD.

A Simulated Patient Protocol for Implementing Evidence-Based Practices in Health Care Delivery.

Background: Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. The goal of this study is to describe the use of simulated patient (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. The primary outcome was identifying likely facilitators for the successful implementation of EBP. Our secondary outcome was the assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. Methods: We observed 12 primary care clinicians' first-time experiences with six unique decision-making algorithms for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain over Zoom. Each clinician was paired with two simulated patients trained to portray individuals with one of the concerning behaviors addressed by the algorithms. The Standardized Patient-evaluations were followed by CFIR guided one-on-one interviews with the clinicians. Results: The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. Conclusions: SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients.

Innovative Research Methods: Using Simulation to Evaluate Health Care Policy.

Statement Health care policies have the potential to improve patient outcomes, access to care, and reduce health disparities. However, new policy is often tested in the field, where unintended consequences are paid for by patients. In this perspective, we argue that health care simulations, which can elucidate the potential for policy to hinder clinicians' ability to provide high-quality care, are a complement to large-scale policy evaluations in the field.

Patients With Acute-on-Chronic Liver Failure Have Greater Healthcare Resource Utilization After Liver Transplantation.

BACKGROUND & AIMS: Although liver transplantation (LT) has been demonstrated to provide survival benefit for patients with acute-on-chronic liver failure (ACLF), data are lacking regarding resource utilization for this population after LT. METHODS: We retrospectively reviewed data from 10 centers in North America of patients transplanted between 2018 and 2019. ACLF was identified by using the European Association for the Study of the Liver-Chronic Liver Failure criteria. RESULTS: We studied 318 patients of whom 106 patients (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Healthcare resource utilization after LT was greater among recipients with ACLF compared with patients without ACLF regarding median post-LT length of hospital stay (LOS) (P < .001), length of post-LT dialysis (P < .001), discharge to a rehabilitation center (P < .001), and 30-day readmission rates (P = .042). Multivariable negative binomial regression analysis demonstrated a significantly longer LOS for patients with ACLF-1 (1.9 days; 95% confidence interval [CI], 0.82-7.51), ACLF-2 (6.7 days; 95% CI, 2.5-24.3), and ACLF-3 (19.3 days; 95% CI, 1.2-39.7), compared with recipients without ACLF. Presence of ACLF-3 at LT was also associated with longer length of dialysis after LT (9.7 days; 95% CI, 4.6-48.8) relative to lower grades. Multivariable logistic regression analysis revealed greater likelihood of discharge to a rehabilitation center among recipients with ACLF-1 (odds ratio [OR], 1.79; 95% CI, 1.09-4.54), ACLF-2 (OR, 2.23; 95% CI, 1.12-5.01), and ACLF-3 (OR, 2.23; 95% CI, 1.40-5.73). Development of bacterial infection after LT also predicted LOS (20.9 days; 95% CI, 6.1-38.5) and 30-day readmissions (OR, 1.39; 95% CI, 1.17-2.25). CONCLUSIONS: Patients with ACLF at LT, particularly ACLF-3, have greater post-transplant healthcare resource utilization.

Diagnosis and management of hepatic encephalopathy: A summary for patients.

Content available: Author Interview and Audio Recording.

Risk Factors for Posttransplantation Mortality in Recipients With Grade 3 Acute-on-Chronic Liver Failure: Analysis of a North American Consortium.

Although liver transplantation (LT) yields survival benefit for patients with acute-on-chronic liver failure grade 3 (ACLF-3), knowledge gaps remain regarding risk factors for post-LT mortality. We retrospectively reviewed data from 10 centers in the United States and Canada for patients transplanted between 2018 and 2019 and who required care in the intensive care unit prior to LT. ACLF was identified using the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria. A total of 318 patients were studied, of whom 106 (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Survival probability 1 year after LT was significantly higher in patients without ACLF (94.3%) compared with patients with ACLF (87.3%; P = 0.02), but similar between ACLF-1 (88.5%), ACLF-2 (87.8%), and ACLF-3 (85.7%; P = 0.26). Recipients with ACLF-3 and circulatory failure (n = 29) had similar 1-year post-LT survival (82.3%) compared with patients with ACLF-3 without circulatory failure (89.6%; P = 0.32), including those requiring multiple vasopressors. For patients transplanted with ACLF-3 including respiratory failure (n = 20), there was a trend toward significantly lower post-LT survival (P =  0.07) among those with respiratory failure (74.1%) compared with those without (91.0%). The presence of portal vein thrombosis (PVT) at LT for patients with ACLF-3 (n = 15), however, yielded significantly lower survival (91.9% versus 57.1%; P < 0.001). Multivariable logistic regression analysis revealed that PVT was significantly associated with post-LT mortality within 1 year (odds ratio, 7.3; 95% confidence interval, 1.9-28.3). No correlation was found between survival after LT and the location or extent of PVT, presence of transjugular intrahepatic portosystemic shunt, or anticoagulation. LT in patients with ACLF-3 requiring vasopressors yields excellent 1-year survival. LT should be approached cautiously among candidates with ACLF-3 and PVT.

EGFR transactivates RON to drive oncogenic crosstalk.

Crosstalk between different receptor tyrosine kinases (RTKs) is thought to drive oncogenic signaling and allow therapeutic escape. EGFR and RON are two such RTKs from different subfamilies, which engage in crosstalk through unknown mechanisms. We combined high-resolution imaging with biochemical and mutational studies to ask how EGFR and RON communicate. EGF stimulation promotes EGFR-dependent phosphorylation of RON, but ligand stimulation of RON does not trigger EGFR phosphorylation - arguing that crosstalk is unidirectional. Nanoscale imaging reveals association of EGFR and RON in common plasma membrane microdomains. Two-color single particle tracking captured formation of complexes between RON and EGF-bound EGFR. Our results further show that RON is a substrate for EGFR kinase, and that transactivation of RON requires formation of a signaling competent EGFR dimer. These results support a role for direct EGFR/RON interactions in propagating crosstalk, such that EGF-stimulated EGFR phosphorylates RON to activate RON-directed signaling.

Treatment and Prevention of Acute Hepatitis B Virus.

This article reviews the incidence of acute hepatitis B virus (HBV) infection, its clinical course, strategies to prevent acute HBV infection in susceptible individuals, and the management of patients with acute HBV.

Multiphoton imaging and Raman spectroscopy of the bovine vertebral endplate.

The interface between the intervertebral disc and the vertebral body is important to the discs' biomechanics and physiology, and is widely implicated in its pathology. This study aimed to explore biochemically and structurally the bony endplate, cartilage endplate and intervertebral disc, below the nucleus and below the annulus in healthy bovine tails. Multiphoton imaging and spontaneous Raman spectroscopy were employed. Raman spectroscopy provided relative quantification of mineral and matrix components across the vertebral endplate and its adjacent areas with microscopic spatial resolution. Microscopy utilising second-harmonic generation (SHG) and two-photon fluorescence (TPF) allowed for the structural identification of distinct endplate regions. The cartilage endplate was revealed as structurally distinct from both the bone and disc, supporting its biomechanical function as a transition zone between the soft and hard tissue components. The collagen fibres were continuous across the tidemark which defines the interface between the mineralised and non-mineralised regions of the endplate. Raman spectroscopy revealed gradients in phosphate and carbonate content through the depth of the endplate and also differences beneath the nucleus and annulus consistent with a higher rate of remodelling under the annulus.

Multidisciplinary Team Management of Hepatocellular Carcinoma Is Standard of Care.

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality, but unlike other leading causes of cancer death, HCC is increasing in mortality and burden of management. Management of HCC is unique because it usually arises in a diseased liver, which itself may be a driver of mortality. Multidisciplinary teams (MDTs) for the management of complex diseases are becoming more common, but are especially needed in the management of patients with HCC. Liver cancer MDTs are used in most centers providing comprehensive care for patients with HCC, and should be considered the standard of care for these patients.

Employing photoluminescence to rapidly follow aggregation and dispersion of cellulose nanofibrils.

Photoluminescence of cellulose, and other polysaccharides, has long been presumed to be due to contamination of the material by other autofluorescent compounds - such as lignin, or proteins. This is attributed to the lack of known fluorescent chemical groups present in the molecular structure of polysaccharides and the weak emission intensity when compared to typical fluorophores. However, recent research suggests that the observed luminescence may actually be due to transitions involving the n orbitals containing lone electron pairs present in oxyl groups, stabilised by the molecular forces between the polysaccharide chains. Here we investigate this theory further by varying the physicochemical environment (concentration and pH) of oxidised cellulose nanofibril suspensions and observing the resultant fluorescent spectra using multi-channel confocal laser scanning spectroscopy. We confirm that both factors affect the material photoluminescence, specifically changing the intensity ratio between two localised emission maxima, supporting current theories. Furthermore, we demonstrate that this variation enables the determination of critical aggregation concentrations and the apparent pKa values of hydroxyl groups that undergo deprotonation within the examined pH range, enabling use of the technique to track rapid changes in the fibril physicochemical environment.

Cautionary study on the effects of pay for performance on quality of care: a pilot randomised controlled trial using standardised patients.

BACKGROUND: Due to the difficulty of studying incentives in practice, there is limited empirical evidence of the full-impact pay-for-performance (P4P) incentive systems. OBJECTIVE: To evaluate the impact of P4P in a controlled, simulated environment. DESIGN: We employed a simulation-based randomised controlled trial with three standardised patients to assess advanced practice providers' performance. Each patient reflected one of the following: (A) indicated for P4P screenings, (B) too young for P4P screenings, or (C) indicated for P4P screenings, but screenings are unrelated to the reason for the visit. Indication was determined by the 2016 Centers for Medicare and Medicaid Services quality measures. INTERVENTION: The P4P group was paid $150 and received a bonus of $10 for meeting each of five outcome measures (breast cancer, colorectal cancer, pneumococcal, tobacco use and depression screenings) for each of the three cases (max $300). The control group received $200. SETTING: Learning resource centre. PARTICIPANTS: 35 advanced practice primary care providers (physician assistants and nurse practitioners) and 105 standardised patient encounters. MEASUREMENTS: Adherence to incentivised outcome measures, interpersonal communication skills, standards of care, and misuse. RESULTS: The Type a patient was more likely to receive indicated P4P screenings in the P4P group (3.82 out of 5 P4P vs 2.94 control, p=0.02), however, received lower overall standards of care under P4P (31.88 P4P vs 37.06 control, p=0.027). The Type b patient was more likely to be prescribed screenings not indicated, but highlighted by P4P: breast cancer screening (47% P4P vs 0% control, p<0.01) and colorectal cancer screening (24% P4P vs 0% control, p=0.03). The P4P group over-reported completion of incentivised measures resulting in overpayment (average of $9.02 per patient). LIMITATIONS: A small sample size and limited variability in patient panel limit the generalisability of findings. CONCLUSIONS: Our findings caution the adoption of P4P by highlighting the unintended consequences of the incentive system.

Systematic Review of Yoga and Balance: Effect on Adults With Neuromuscular Impairment.

This systematic review examines the efficacy of yoga as a neuromuscular intervention for community-dwelling populations at risk for falls to determine its utility for use in occupational therapy intervention. Populations included older adults and adults with traumatic brain injury (TBI), cerebrovascular accident (CVA), dementia and Alzheimer's disease (AD)-type dementia, multiple sclerosis (MS), and Parkinson's disease (PD). Benefits of yoga include improved posture control, improved flexibility of mind and body, relaxation, and decreased anxiety and stress. A systematic review of the literature was conducted to understand the salutary benefits of yoga for clients who are at risk for falls because of neuromuscular issues. Moderate evidence supports the use of yoga to decrease the risk for falls for community-dwelling older adults and people with CVA, dementia and AD-type dementia, and MS. Studies involving people with TBI and PD did not include strong enough evidence to be able to make a clear classification.

Assessment of Compressive Raman versus Hyperspectral Raman for Microcalcification Chemical Imaging.

We experimentally implement a compressive Raman technology (CRT) that incorporates chemometric analysis directly into the spectrometer hardware by means of a digital micromirror device (DMD). The DMD is a programmable optical filter on which optimized binary filters are displayed. The latter are generated with an algorithm based on the Cramer-Rao lower bound. We compared the developed CRT microspectrometer with two conventional state-of-the-art Raman hyperspectral imaging systems on samples mimicking microcalcifications relevant for breast cancer diagnosis. The CRT limit of detection significantly improves, when compared to the CCD based system, and CRT ultimately allows 100× and 10× faster acquisition speeds than the CCD- and EMCCD-based systems, respectively.