The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study.

BACKGROUND: The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK. METHODS: A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR). RESULTS: Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services. CONCLUSIONS: Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.

Statin Therapy for Secondary Prevention in Ischemic Stroke Patients With Cerebral Microbleeds.

BACKGROUND AND OBJECTIVES: The association between statin use and the risk of intracranial hemorrhage (ICrH) following ischemic stroke (IS) or transient ischemic attack (TIA) in patients with cerebral microbleeds (CMBs) remains uncertain. This study investigated the risk of recurrent IS and ICrH in patients receiving statins based on the presence of CMBs. METHODS: We conducted a pooled analysis of individual patient data from the Microbleeds International Collaborative Network, comprising 32 hospital-based prospective studies fulfilling the following criteria: adult patients with IS or TIA, availability of appropriate baseline MRI for CMB quantification and distribution, registration of statin use after the index stroke, and collection of stroke event data during a follow-up period of ≥3 months. The primary endpoint was the occurrence of recurrent symptomatic stroke (IS or ICrH), while secondary endpoints included IS alone or ICrH alone. We calculated incidence rates and performed Cox regression analyses adjusting for age, sex, hypertension, atrial fibrillation, previous stroke, and use of antiplatelet or anticoagulant drugs to explore the association between statin use and stroke events during follow-up in patients with CMBs. RESULTS: In total, 16,373 patients were included (mean age 70.5 ± 12.8 years; 42.5% female). Among them, 10,812 received statins at discharge, and 4,668 had 1 or more CMBs. The median follow-up duration was 1.34 years (interquartile range: 0.32-2.44). In patients with CMBs, statin users were compared with nonusers. Compared with nonusers, statin therapy was associated with a reduced risk of any stroke (incidence rate [IR] 53 vs 79 per 1,000 patient-years, adjusted hazard ratio [aHR] 0.68 [95% CI 0.56-0.84]), a reduced risk of IS (IR 39 vs 65 per 1,000 patient-years, aHR 0.65 [95% CI 0.51-0.82]), and no association with the risk of ICrH (IR 11 vs 16 per 1,000 patient-years, aHR 0.73 [95% CI 0.46-1.15]). The results in aHR remained consistent when considering anatomical distribution and high burden (≥5) of CMBs. DISCUSSION: These observational data suggest that secondary stroke prevention with statins in patients with IS or TIA and CMBs is associated with a lower risk of any stroke or IS without an increased risk of ICrH. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with IS or TIA and CMBs, statins lower the risk of any stroke or IS without increasing the risk of ICrH.

Cost-effectiveness of an individualised management program after stroke: a trial-based economic evaluation.

INTRODUCTION: Evidence on the cost-effectiveness of comprehensive post-stroke programs is limited. We assessed the cost-effectiveness of an individualised management program (IMP) for stroke or transient ischaemic attack (TIA). METHODS: A cost-utility analysis alongside a randomised controlled trial with a 2-year follow-up, from both societal and health system perspectives, was conducted. Adults with stroke/TIA discharged from hospitals were randomised by primary care practice to receive either usual care (UC) or an IMP in addition to UC. An IMP included at-home stroke-specific nurse-led education and a specialist review of care plans at baseline, 3, and 12 months, and telephone reviews by nurses at 6 and 18 months. Costs in 2021 Australian dollars (AUD) and quality-adjusted life years (QALYs) were discounted by 5%. The probability of cost-effectiveness of the intervention was determined by quantifying 10,000 bootstrapped iterations of incremental costs and QALYs below the threshold of AUD50,000/QALY. RESULTS: Among the 502 participants (65% male, median age 69 years), 251 (50%) were in the intervention group. From a health system perspective, the incremental cost per QALY gained was AUD53,175 with an IMP compared to UC alone. At a willingness-to-pay threshold of AUD50,000/QALY, an IMP was preferred in 46.7% of iterations. From a societal perspective, the intervention was dominant in 52.7% of iterations with mean per-patient costs of AUD49,045 and 1.352 QALYs compared to mean per-patient costs of AUD51,394 and 1.324 QALYs in the UC group. The probability of cost-effectiveness of an IMP, from a societal perspective, was 60.5%. CONCLUSIONS: Care for people with stroke/TIA using an IMP was cost-effective from a societal perspective over two years. Economic evaluations of prevention programs need sufficient time horizons and consideration of costs beyond direct health care utilisation to demonstrate their value to society.

Healthcare consumer acceptability of routine use of the EQ-5D-5L in clinical care: a cross-sectional survey.

PURPOSE: Patient reported outcome measures, such as the EQ-5D-5L, provide a measure of self-perceived health status or health-related quality of life. Understanding the consumer acceptability of a patient reported outcome measure can help to decide about its implementation across a healthcare organisation and possibly increase the likelihood of its use in clinical care. This study established the acceptability of the EQ-5D-5L from the perspective of clients receiving healthcare, and determined if acceptability varied by client sub-types. METHODS: A cross-sectional survey explored clients' experience of the EQ-5D-5L. Eligible clients were aged ≥ 18 years and completed the EQ-5D-5L on admission and discharge to one of two multi-disciplinary community health services. Likert scale items explored acceptability, and open-ended questions determined if the EQ-5D-5L reflects experience of illness. Associations between acceptability and client characteristics were established using χ2 test. Open-ended questions were analysed using content analysis. RESULTS: Most of the 304 clients (mean age 70 years, SD 16) agreed that the EQ-5D-5L: was easy to use/understand (n = 301, 99%) and useful (n = 289, 95%); improved communication with their therapist (n = 275, 90%); and made them feel more in control of their health (n = 276, 91%). Most clients also agreed that they wished to continue using the EQ-5D-5L (n = 285, 93%). Clients aged ≥ 60 years reported lower acceptability. Clients noted that the EQ-5D-5L did not capture experience of illness related to fatigue, balance/falls, cognition, and sleep. CONCLUSION: The EQ-5D-5L is acceptable for use in care but does not capture all aspects of health relevant to clients, and acceptability varies by subgroup.

Risk factors for incident cardiovascular events and their population attributable fractions in rural India: The Rishi Valley Prospective Cohort Study.

OBJECTIVE: We prospectively determined incident cardiovascular events and their association with risk factors in rural India. METHODS: We followed up with 7935 adults from the Rishi Valley Prospective Cohort Study to identify incident cardiovascular events. Using Cox proportional hazards regression, we estimated hazard ratios (HRs) with 95% confidence intervals (95% CI) for associations between potential risk factors and cardiovascular events. Population attributable fractions (PAFs) for risk factors were estimated using R ('averisk' package). RESULTS: Of the 4809 participants without prior cardiovascular disease, 57.7% were women and baseline mean age was 45.3 years. At follow-up (median of 4.9 years, 23,180 person-years [PYs]), 202 participants developed cardiovascular events, equating to an incidence of 8.7 cardiovascular events/1000 PYs. Incidence was greater in those with hypertension (hazard ratio [HR] [95% CI] 1.73 [1.21-2.49], adjusted PAF 18%), diabetes (1.96 [1.15-3.36], 4%) or central obesity (1.77 [1.23, 2.54], 9%) which together accounted for 31% of the PAF. Non-traditional risk factors such as night sleeping hours and number of children accounted for 16% of the PAF. CONCLUSIONS: Both traditional and non-traditional cardiovascular risk factors are important contributors to incident cardiovascular events in rural India. Interventions targeted to these factors could assist in reducing the incidence of cardiovascular events.

Clinical Associations and Prognostic Value of MRI-Visible Perivascular Spaces in Patients With Ischemic Stroke or TIA: A Pooled Analysis

BACKGROUND AND OBJECTIVES: Visible perivascular spaces are an MRI marker of cerebral small vessel disease and might predict future stroke. However, results from existing studies vary. We aimed to clarify this through a large collaborative multicenter analysis. METHODS: We pooled individual patient data from a consortium of prospective cohort studies. Participants had recent ischemic stroke or transient ischemic attack (TIA), underwent baseline MRI, and were followed up for ischemic stroke and symptomatic intracranial hemorrhage (ICH). Perivascular spaces in the basal ganglia (BGPVS) and perivascular spaces in the centrum semiovale (CSOPVS) were rated locally using a validated visual scale. We investigated clinical and radiologic associations cross-sectionally using multinomial logistic regression and prospective associations with ischemic stroke and ICH using Cox regression. RESULTS: We included 7,778 participants (mean age 70.6 years; 42.7% female) from 16 studies, followed up for a median of 1.44 years. Eighty ICH and 424 ischemic strokes occurred. BGPVS were associated with increasing age, hypertension, previous ischemic stroke, previous ICH, lacunes, cerebral microbleeds, and white matter hyperintensities. CSOPVS showed consistently weaker associations. Prospectively, after adjusting for potential confounders including cerebral microbleeds, increasing BGPVS burden was independently associated with future ischemic stroke (versus 0-10 BGPVS, 11-20 BGPVS: HR 1.19, 95% CI 0.93-1.53; 21+ BGPVS: HR 1.50, 95% CI 1.10-2.06; p = 0.040). Higher BGPVS burden was associated with increased ICH risk in univariable analysis, but not in adjusted analyses. CSOPVS were not significantly associated with either outcome. DISCUSSION: In patients with ischemic stroke or TIA, increasing BGPVS burden is associated with more severe cerebral small vessel disease and higher ischemic stroke risk. Neither BGPVS nor CSOPVS were independently associated with future ICH.

Type 2 Diabetes and Biomarkers of Brain Structure, Perfusion, Metabolism, and Function in Late Mid-Life: A Multimodal Discordant Twin Study.

BACKGROUND: Type 2 diabetes (T2D) is associated with an increased risk of dementia and early features may become evident even in mid-life. Characterizing these early features comprehensively requires multiple measurement modalities and careful selection of participants with and without T2D. OBJECTIVE: We conducted a cross-sectional multimodal imaging study of T2D-discordant twins in late mid-life to provide insights into underlying mechanisms. METHODS: Measurements included computerized cognitive battery, brain MRI (including arterial spin labelling, diffusion tensor, resting state functional), fluorodeoxyglucose (FDG)-PET, and retinal optical coherence tomography. RESULTS: There were 23 pairs, mean age 63.7 (±6.1) years. In global analyses, T2D was associated with poorer attention (ß= -0.45, p <0.001) and with reduced FDG uptake (ß= -5.04, p = 0.02), but not with cortical thickness (p = 0.71), total brain volume (p = 0.51), fractional anisotropy (p = 0.15), mean diffusivity (p = 0.34), or resting state activity (p = 0.4). Higher FDG uptake was associated with better attention (ß= 3.19, p = 0.01) but not with other cognitive domains. In regional analyses, T2D was associated with lower accumbens volume (ß= -44, p = 0.0004) which was in turn associated with poorer attention. CONCLUSION: T2D-related brain dysfunction in mid-life manifests as attentional loss accompanied by evidence of subtle neurodegeneration and global reduction in cerebral metabolism, in the absence of overt cerebrovascular disease.

Cost-effectiveness of a government policy to incentivise chronic disease management following stroke: a modelling study.

BACKGROUND: Little is known about the cost-effectiveness of government policies that support primary care physicians to provide comprehensive chronic disease management (CDM). AIMS: To estimate the potential cost-effectiveness of CDM policies, over a lifetime, in long-time survivors of stroke. METHODS: A Markov model, using three health states (stable, hospitalised, dead), was developed to simulate the costs and benefits of CDM policies over 30 years (with 1-year cycles). Transition probabilities and costs from a health system perspective were obtained from the linkage of data between the Australian Stroke Clinical Registry (cohort n=12,368, 42% female, median age 70 years, 45% had a claim) and government-held hospital, Medicare, and pharmaceutical claims datasets. Quality-adjusted life years (QALYs) were obtained from a comparable cohort (n=512, 34% female, median age 69.6 years, 52% had a claim) linked with Medicare claims and death data. A 3% discount rate was applied to costs in Australian dollars (AUD, 2016) and QALYs beyond 12 months. Probabilistic sensitivity analyses were used to understand uncertainty. RESULTS: Per-person average total lifetime costs were AUD142,939 and 8.97 QALYs for those with a claim, and AUD103,889 and 8.98 QALYs for those without a claim. This indicates that these CDM policies were costlier without improving QALYs. The probability of cost-effectiveness of CDM was 26.1%, at a willingness-to-pay threshold of AUD50,000/QALY. CONCLUSION: CDM policies, designed to encourage comprehensive care, are unlikely to be cost-effective for stroke compared to care without CDM. Further research to understand how to deliver such care in a cost-effective manner is needed.

Using a multi-stakeholder co-design process to develop a health service organisation-wide patient reported outcome measure collection system.

PURPOSE: Limited examples exist of successful Patient Reported Outcome Measure (PROM) implementation across an entire healthcare organisation. The aim of this study was to use a multi-stakeholder co-design process to develop a PROM collection system, which will inform implementation of routine collection of PROMs across an entire healthcare organisation. METHODS: Co-design comprised semi-structured interviews with clinicians (n = 11) and workshops/surveys with consumers (n = 320). The interview guide with clinicians focused on their experience using PROMs, preferences for using PROMs, and facilitators/barriers to using PROMs. Co-design activities specific to consumers focused on: (1) how PROMs will be administered (mode), (2) when PROMs will be administered (timing), (3) who will assist with PROMs collection, and (4) how long a PROM will take to complete. Data were analysed using a manifest qualitative content analysis approach. RESULTS: Core elements identified during the co-design process included: PROMs collection should be consumer-led and administered by someone other than a clinician; collection at discharge from the healthcare organisation and at 3-6 months post discharge would be most suitable for supporting comprehensive assessment; PROMs should be administered using a variety of modes to accommodate the diversity of consumer preferences, with electronic as the default; and the time taken to complete PROMs should be no longer than 5-10 min. CONCLUSION: This study provides new information on the co-design of a healthcare organisation-wide PROM collection system. Implementing a clinician and patient informed strategy for PROMs collection, that meets their preferences across multiple domains, should address known barriers to routine collection.

Comparison of the performance of cardiovascular risk prediction tools in rural India: the Rishi Valley Prospective Cohort Study.

AIMS: We compared the performance of cardiovascular risk prediction tools in rural India. METHODS AND RESULTS: We applied the World Health Organization Risk Score (WHO-RS) tools, Australian Risk Score (ARS), and Global risk (Globorisk) prediction tools to participants aged 40-74 years, without prior cardiovascular disease, in the Rishi Valley Prospective Cohort Study, Andhra Pradesh, India. Cardiovascular events during the 5-year follow-up period were identified by verbal autopsy (fatal events) or self-report (non-fatal events). The predictive performance of each tool was assessed by discrimination and calibration. Sensitivity and specificity of each tool for identifying high-risk individuals were assessed using a risk score cut-off of 10% alone or this 10% cut-off plus clinical risk criteria of diabetes in those aged >60 years, high blood pressure, or high cholesterol. Among 2333 participants (10 731 person-years of follow-up), 102 participants developed a cardiovascular event. The 5-year observed risk was 4.4% (95% confidence interval: 3.6-5.3). The WHO-RS tools underestimated cardiovascular risk but the ARS overestimated risk, particularly in men. Both the laboratory-based (C-statistic: 0.68 and χ2: 26.5, P = 0.003) and non-laboratory-based (C-statistic: 0.69 and χ2: 20.29, P = 0.003) Globorisk tools showed relatively good discrimination and agreement. Addition of clinical criteria to a 10% risk score cut-off improved the diagnostic accuracy of all tools. CONCLUSION: Cardiovascular risk prediction tools performed disparately in a setting of disadvantage in rural India, with the Globorisk performing best. Addition of clinical criteria to a 10% risk score cut-off aids assessment of risk of a cardiovascular event in rural India. LAY SUMMARY: In a cohort of people without prior cardiovascular disease, tools used to predict the risk of cardiovascular events varied widely in their ability to accurately predict who would develop a cardiovascular event.The Globorisk, and to a lesser extent the ARS, tools could be appropriate for this setting in rural India.Adding clinical criteria, such as sustained high blood pressure, to a cut-off of 10% risk of a cardiovascular event within 5 years could improve identification of individuals who should be monitored closely and provided with appropriate preventive medications.

Exploring associations of greenery, air pollution and walkability with cardiometabolic health in people at midlife and beyond.

AIM: To examine associations of neighborhood greenery, air pollution and walkability with cardiometabolic disease in adults aged ≥45 years in the Frankston-Mornington Peninsula region, Victoria, Australia. METHODS: A cross-sectional, ecological study design was used. We assessed mean annual neighborhood greenery using the Normalized Difference Vegetation Index; air pollution (fine particulate matter of diameter ≤2.5 µm [PM2.5] and NO2) using land-use regression models; and walkability using Walk Score (possible values 0-100). Medically diagnosed diabetes (~95% type-2), heart disease and stroke were self-reported in the Australian Census (2021). Multivariable regression was used to model associations between environmental exposures and area-level (neighborhood) cardiometabolic disease prevalence (age group ≥45 years), with socioeconomic status, age and sex as covariates. Air pollution was examined as a mediator of associations between greenery and disease prevalence. RESULTS: Our sample comprised 699 neighborhoods with the following mean (SD) values: Normalized Difference Vegetation Index 0.47 (0.09), PM2.5, 8.5 (0.6) µg/m3 and NO2, 5.2 (1.6) ppb. Disease prevalences were: heart disease, mean 8.9% (4.5%); diabetes, mean 10.3% (4.7%); and stroke, median 1.2% (range 0-10.9%). Greenery was negatively associated with diabetes (ß = -5.85, 95% CI -9.53, -2.17) and stroke prevalence (ß = -1.26, 95% CI -2.11, -0.42). PM2.5 and NO2 were positively associated with diabetes (ß = 1.59, 95% CI 1.00, 2.18; ß = 0.42, 95% CI 0.22, 0.62) and stroke prevalence (ß = 0.15, 95% CI 0.01, 0.29; ß = 0.06, 95% CI 0.01, 0.10). The association between greenery and diabetes was partially mediated by PM2.5 (mediated effect -5.38, 95% CI -7.84, -3.03). CONCLUSIONS: Greenery and air pollutants were associated with lower and higher prevalence, respectively, of self-reported diabetes and, to a lesser extent, stroke. These ecological findings require further exploration with stronger, longitudinal study designs to inform public health policy and directions. Geriatr Gerontol Int 2024; 24: 208-214.

Perceptions of Barriers and Facilitators to a Pilot Implementation of an Algorithm-Supported Care Navigation Model of Care: A Qualitative Study.

We aimed to explore managerial and project staff perceptions of the pilot implementation of an algorithm-supported care navigation model, targeting people at risk of hospital readmission. The pilot was implemented from May to November 2017 at a Victorian health service (Australia) and provided to sixty-five patients discharged from the hospital to the community. All managers and the single clinician involved participated in a semi-structured interview. Participants (n = 6) were asked about their perceptions of the service design and the enablers and barriers to implementation. Interviews were transcribed verbatim and analysed according to a framework approach, using inductive and deductive techniques. Constructed themes included the following: an algorithm alone is not enough, the health service culture, leadership, resources and the perceived patient experience. Participants felt that having an algorithm to target those considered most likely to benefit was helpful but not enough on its own without addressing other contextual factors, such as the health service's capacity to support a large-scale implementation. Deductively mapping themes to the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework highlighted that a formal facilitation would be essential for future sustainable implementations. The systematic identification of barriers and enablers elicited critical information for broader implementations of algorithm-supported models of care.

Factors Associated With Transition From Community to Permanent Residential Aged Care Following Stroke: A Linked Registry Data Study.

BACKGROUND: Understanding factors that influence the transition to permanent residential aged care following a stroke or transient ischemic attack may inform strategies to support people to live at home longer. We aimed to identify the demographic, clinical, and system factors that may influence the transition from living in the community to permanent residential care in the 6 to 18 months following stroke/transient ischemic attack. METHODS: Linked data cohort analysis of adults from Queensland and Victoria aged ≥65 years and registered in the Australian Stroke Clinical Registry (2012-2016) with a clinical diagnosis of stroke/transient ischemic attack and living in the community in the first 6 months post-hospital discharge. Participant data were linked with primary care, pharmaceutical, aged care, death, and hospital data. Multivariable survival analysis was performed to determine demographic, clinical, and system factors associated with the transition to permanent residential care in the 6 to 18 months following stroke, with death modeled as a competing risk. RESULTS: Of 11 176 included registrants (median age, 77.2 years; 44% female), 520 (5%) transitioned to permanent residential care between 6 and 18 months. Factors most associated with transition included the history of urinary tract infections (subhazard ratio [SHR], 1.41 [95% CI, 1.16-1.71]), dementia (SHR, 1.66 [95% CI, 1.14-2.42]), increasing age (65-74 versus 85+ years; SHR, 1.75 [95% CI, 1.31-2.34]), living in regional Australia (SHR, 31 [95% CI, 1.08-1.60]), and aged care service approvals: respite (SHR, 4.54 [95% CI, 3.51-5.85]) and high-level home support (SHR, 1.80 [95% CI, 1.30-2.48]). Protective factors included being dispensed antihypertensive medications (SHR, 0.68 [95% CI, 0.53-0.87]), seeing a cardiologist (SHR, 0.72 [95% CI, 0.57-0.91]) following stroke, and less severe stroke (SHR, 0.71 [95% CI, 0.58-0.88]). CONCLUSIONS: Our findings provide an improved understanding of factors that influence the transition from community to permanent residential care following stroke and can inform future strategies designed to delay this transition.

Developing a linked electronic health record derived data platform to support research into healthy ageing.

Introduction: Digitalisation of Electronic Health Record (EHR) data has created unique opportunities for research. However, these data are routinely collected for operational purposes and so are not curated to the standard required for research. Harnessing such routine data at large scale allows efficient and long-term epidemiological and health services research. Objectives: To describe the establishment a linked EHR derived data platform in the National Centre for Healthy Ageing, Melbourne, Australia, aimed at enabling research targeting national health priority areas in ageing. Methods: Our approach incorporated: data validation, curation and warehousing to ensure quality and completeness; end-user engagement and consensus on the platform content; implementation of an artificial intelligence (AI) pipeline for extraction of text-based data items; early consumer involvement; and implementation of routine collection of patient reported outcome measures, in a multisite public health service. Results: Data for a cohort of >800,000 patients collected over a 10-year period have been curated within the platform's research data warehouse. So far 117 items have been identified as suitable for inclusion, from 11 research relevant datasets held within the health service EHR systems. Data access, extraction and release processes, guided by the Five Safes Framework, are being tested through project use-cases. A natural language processing (NLP) pipeline has been implemented and a framework for the routine collection and incorporation of patient reported outcome measures developed. Conclusions: We highlight the importance of establishing comprehensive processes for the foundations of a data platform utilising routine data not collected for research purposes. These robust foundations will facilitate future expansion through linkages to other datasets for the efficient and cost-effective study of health related to ageing at a large scale.

Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation.

PURPOSE: To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks. MATERIALS AND METHODS: A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised. RESULTS: Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians' "belief about consequences", "reinforcement", and "environmental context and resources". Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support. CONCLUSIONS: Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision.

Implementation of patient reported outcome measures within multidiscipline rehabilitation settings are likely optimised by establishing infrastructure support e.g., information technology systems to automate the process and minimise manual aspects of data collection.Engaging site champions may be an important enabler for the routine collection of patient reported outcome measuresProviding feedback to clinicians on aggregated results of patient reported outcome measures are likely to motivate and encourage routine collection.

Acceptability of the routine use and collection of a generic patient reported outcome measure from the perspective of healthcare staff: a qualitative study.

BACKGROUND: Patient-reported outcome measures (PROMs) provide a measure of self-perceived health status or health-related quality of life. They have been used to support provider-patient decisions, healthcare delivery, and value-based healthcare models. A barrier to routine collection of PROMs is the perception that PROMs lack clinical utility. As such, it is important to establish clinicians' acceptability of the PROM prior to large-scale implementation. This study explored the acceptability of the routine use and collection of a generic PROM in healthcare services from the perspective of healthcare staff. METHODS: Individual semi-structured interviews were completed from September 2020 to March 2021 with 26 staff from two multi-disciplinary community healthcare services in Melbourne, Australia. Interviews explored their experiences of using the EQ-5D-5L in their routine care. Interviews were recorded and transcribed verbatim. Data were analysed according to a framework approach, using inductive and deductive techniques. RESULTS: Participants discussed the acceptability of the EQ-5D-5L with reference to four themes: practicalities of use; holistic nature; influence on client care; and influence on health service. Participants found the EQ-5D-5L quick and easy to administer, and appreciated that it measured multiple domains of health that were relevant to their clients' care. They believed the EQ-5D-5L helped to identify client problems, and inform service delivery. They also reported features that were less acceptable, including a lack of item specificity to some healthcare disciplines. Participants reported the challenge of managing conflict between their assessment of the client's health and the client's perspective of their own health, leading some to question whether the client could provide an accurate reflection of their own health. CONCLUSIONS: The EQ-5D-5L has several features that healthcare staff viewed as acceptable for routine collection and use in healthcare. Training on the validity of the patient reported perspective and broadening the scope of PROMs collection beyond the EQ-5D-5L should be considered to facilitate large-scale implementation.

The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach.

Background: Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Methods: Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012-December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7-18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. Findings: 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Interpretation: Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA. Funding: National Health and Medical Research Council Australia.

Prospective application of theoretical implementation frameworks to improve health care in hospitals - a systematic review.

BACKGROUND: Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes. METHOD: We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1st January 1995 to 15th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category. RESULTS: Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results. CONCLUSIONS: Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base. TRIAL REGISTRATION: CRD42019119429.