To what extent can behaviour change techniques be identified within an adaptable implementation package for primary care? A prospective directed content analysis.

BACKGROUND: Interpreting evaluations of complex interventions can be difficult without sufficient description of key intervention content. We aimed to develop an implementation package for primary care which could be delivered using typically available resources and could be adapted to target determinants of behaviour for each of four quality indicators: diabetes control, blood pressure control, anticoagulation for atrial fibrillation and risky prescribing. We describe the development and prospective verification of behaviour change techniques (BCTs) embedded within the adaptable implementation packages. METHODS: We used an over-lapping multi-staged process. We identified evidence-based, candidate delivery mechanisms-mainly audit and feedback, educational outreach and computerised prompts and reminders. We drew upon interviews with primary care professionals using the Theoretical Domains Framework to explore likely determinants of adherence to quality indicators. We linked determinants to candidate BCTs. With input from stakeholder panels, we prioritised likely determinants and intervention content prior to piloting the implementation packages. Our content analysis assessed the extent to which embedded BCTs could be identified within the packages and compared them across the delivery mechanisms and four quality indicators. RESULTS: Each implementation package included at least 27 out of 30 potentially applicable BCTs representing 15 of 16 BCT categories. Whilst 23 BCTs were shared across all four implementation packages (e.g. BCTs relating to feedback and comparing behaviour), some BCTs were unique to certain delivery mechanisms (e.g. 'graded tasks' and 'problem solving' for educational outreach). BCTs addressing the determinants 'environmental context' and 'social and professional roles' (e.g. 'restructuring the social and 'physical environment' and 'adding objects to the environment') were indicator specific. We found it challenging to operationalise BCTs targeting 'environmental context', 'social influences' and 'social and professional roles' within our chosen delivery mechanisms. CONCLUSION: We have demonstrated a transparent process for selecting, operationalising and verifying the BCT content in implementation packages adapted to target four quality indicators in primary care. There was considerable overlap in BCTs identified across the four indicators suggesting core BCTs can be embedded and verified within delivery mechanisms commonly available to primary care. Whilst feedback reports can include a wide range of BCTs, computerised prompts can deliver BCTs at the time of decision making, and educational outreach can allow for flexibility and individual tailoring in delivery.

Action to Support Practices Implement Research Evidence (ASPIRE): protocol for a cluster-randomised evaluation of adaptable implementation packages targeting 'high impact' clinical practice recommendations in general practice.

BACKGROUND: There are recognised gaps between evidence and practice in general practice, a setting which provides particular challenges for implementation. We earlier screened clinical guideline recommendations to derive a set of 'high impact' indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. We aim to evaluate the effectiveness and cost-effectiveness of a multifaceted, adaptable intervention package to implement four targeted, high impact recommendations in general practice. METHODS/DESIGN: The research programme Action to Support Practice Implement Research Evidence (ASPIRE) includes a pair of pragmatic cluster-randomised trials which use a balanced incomplete block design. Clusters are general practices in West Yorkshire, United Kingdom (UK), recruited using an 'opt-out' recruitment process. The intervention package adapted to each recommendation includes combinations of audit and feedback, educational outreach visits and computerised prompts with embedded behaviour change techniques selected on the basis of identified needs and barriers to change. In trial 1, practices are randomised to adapted interventions targeting either diabetes control or risky prescribing and those in trial 2 to adapted interventions targeting either blood pressure control in patients at risk of cardiovascular events or anticoagulation in atrial fibrillation. The respective primary endpoints comprise achievement of all recommended target levels of haemoglobin A1c (HbA1c), blood pressure and cholesterol in patients with type 2 diabetes, a composite indicator of risky prescribing, achievement of recommended blood pressure targets for specific patient groups and anticoagulation prescribing in patients with atrial fibrillation. We are also randomising practices to a fifth, non-intervention control group to further assess Hawthorne effects. Outcomes will be assessed using routinely collected data extracted 1 year after randomisation. Economic modelling will estimate intervention cost-effectiveness. A process evaluation involving eight non-trial practices will examine intervention delivery, mechanisms of action and unintended consequences. DISCUSSION: ASPIRE will provide 'real-world' evidence about the effects, cost-effectiveness and delivery of adapted intervention packages targeting high impact recommendations. By implementing our adaptable intervention package across four distinct clinical topics, and using 'opt-out' recruitment, our findings will provide evidence of wider generalisability. TRIAL REGISTRATION: ISRCTN91989345.

International priorities for research in nursing informatics for patient care.

The Nursing Informatics International Research Network (NIIRN) is a group of experts who are collaborating on the development of internationally relevant research programs for nursing informatics. In this paper we outline key findings of a survey exploring international research priorities for nursing informatics. The survey was available online during May-August 2012. Respondents were asked to rate each of 20 listed research topics in terms of respondent's views of its priority for nursing informatics research. 468 completed surveys were received representing respondents from six World Health Organization regions. The two most highly ranked areas of importance for research were development of systems to provide real time feedback to nurses and assessment of the impact of HIT on nursing care and patient outcomes. The lowest ranked research topics were theory development and integrating genomic data into clinical information systems. The identification of these priorities provides a basis for future international collaborative research in the field of nursing informatics.

The Clinical Decision Unit has a role to play in the management of acute undifferentiated abdominal pain.

INTRODUCTION AND AIMS: Patients with undifferentiated acute abdominal pain (AAP) frequently present to the Emergency Department (ED). The most common diagnosis is the nonspecific abdominal pain although missed occult surgical pathology in the haemodynamically stable patient with equivocal symptoms and signs is a potential source of morbidity. The objectives of this study were two-fold. Firstly, to ascertain the accuracy of ED clinicians in the diagnosis of AAP, and to delineate if there was a population of patients who would normally require admission to hospital that would be suitable to be managed on a Clinical Decision Unit (CDU) protocol. Secondly, to prospectively evaluate such a strategy by way of a pilot study. METHODS: An initial retrospective cohort study of consecutive patients presenting to the ED with undifferentiated AAP were analysed. Data were extracted on admission, length of stay and the correlation between initial ED clinical diagnosis and final discharge diagnosis. Following this, a protocol was developed within our institution for the management of patients with stable AAP on a CDU pathway. This was then formally evaluated over a period of 25 months as part of a quality improvement exercise. RESULTS: A total of 501 patients were analysed of whom 48% were admitted from the ED. The initial ED diagnosis was correct in 57% of patients, and 28% of admitted patients were discharged within 48 h with no specific intervention. During the period of the pilot study, 189 patients were entered on to the AAP CDU pathway, of which 85% were safely discharged directly from the CDU and 67% within 24 h. Of the 28 patients admitted only four required an operation. Use of the protocol in this population resulted in the initial ED assessment being correct in 69% of cases. CONCLUSION: The management of stable AAP within the ED environment on a well-defined CDU pathway is feasible and can facilitate safe, efficient and effective care with early discharge and an increase in the accuracy of the final diagnosis.

Does computer-aided clinical decision support improve the management of acute abdominal pain? A systematic review.

Acute abdominal pain is a common reason for emergency presentation to hospital. Despite recent medical advances in diagnostics, overall clinical decision-making in the assessment of patients with undifferentiated acute abdominal pain remains poor, with initial clinical diagnostic accuracy being 45-50%. Computer-aided decision support (CADS) systems were widely tested in this arena during the 1970s and 1980s with results that were generally favourable. Inception into routine clinical practice was hampered largely by the size and speed of the hardware. Computer systems and literacy are now vastly superior and the potential benefit of CADS deserves investigation. An extensive literature search was undertaken to find articles that directly compared the clinical diagnostic accuracy prospectively of medical staff in the diagnosis of acute abdominal pain before and after the institution of a CADS programme. Included articles underwent meta-analysis with a random-effects model. Ten studies underwent meta-analysis that demonstrated an overall mean percentage improvement in clinical diagnostic accuracy of 17.25% with the use of CADS systems. There is a role for CADS in the initial evaluation of acute abdominal pain, which very often takes place in the emergency department setting.

Key challenges in the development and implementation of telehealth projects.

A literature review was carried out to identify the key challenges in the implementation of telehealth. This was followed by a survey of organisations in England involved in telehealth projects in order to understand the challenges they faced. Ten of the 13 health or local authority organisations surveyed had telehealth projects and three were at the planning stage. The analysis revealed seven key challenges facing implementers of telehealth in England. Based on the findings from the literature review and the survey, a model was constructed and a checklist drawn up. The model contained the following elements: identifying issues, needs and partners; producing a strategy; securing funding; implementing changes; and monitoring and evaluating a telehealth project. The checklist was validated by using key informants from the organisations originally surveyed. The checklist may be useful to guide telehealth development and implementation in the future.

Health informatics education for clinicians and managers--what's holding up progress?

This paper reports outcomes of a national survey of health informatics (HI) education and training carried out in the UK. A questionnaire to elicit details of HI and IT skills teaching was derived from a national consensus document (Learning to Manage Health Information, LtMHI). Forms were sent to all pre-qualification medical and nursing schools and to a stratified sample of postgraduate and post-registration programmes. Three case studies were carried out in acute hospital trusts to gain insight into opportunities for continuing professional development in health informatics and IT. Our evidence suggests that in the UK, health informatics is not yet integrated into the clinical curriculum. Nearly all the pre-qualification courses made some provision for teaching IT skills. Nonetheless, many respondents felt that students did not receive sufficient training. There was considerable variation in the amount of HI teaching provided in the different educational sectors. The case studies suggested very little HI training was provided for clinical staff and take-up of provision was not monitored. A number of factors are holding up progress, the most important being a lack of staff with the knowledge and skills to provide academic leadership. The paper outlines some steps that need to be taken to ensure health informatics is embedded in all clinical curricula.