The association of the STarT Back Screening Tool and type of leg pain with low back pain disability trajectories: a prospective cohort study.

BACKGROUND: Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of prognostic factors might contribute to a better understanding of the course of LBP. The purpose of this study is to investigate the association of the STarT Back Screening Tool (SBST) risk score and the type of leg pain (non-radiating LBP, referred non-radicular, and radicular radiating leg pain) with the disability trajectory (at baseline, the slope, and recovery at one year) in adults with low back pain. METHODS: This is a prospective cohort study in 347 patients with low back pain who sought physiotherapy care at three primary care practices in the Netherlands. Linear mixed models were estimated to describe the association of the SBST risk score and the type of leg pain with disability at baseline, the slope in the disability trajectory, and at twelve months follow-up. RESULTS: A medium/high risk score on the SBST is associated with higher baseline disability scores on the Oswestry Disability Index (ODI), faster initial recovery, and still a higher disability ODI score at 12 months follow-up. Non-radicular referred and radicular radiating leg pain were associated with worse baseline disability ODI scores in LBP. This association was not present for the initial recovery or at the 12 months follow-up. CONCLUSION: The SBST is associated with the LBP recovery trajectory. The SBST might be a useful tool to predict the disability trajectory in a heterogeneous group of people with low back pain in primary care and might, therefore, be recommended in future clinical practice guidelines. The type of leg pain was not associated with the recovery trajectory of LBP. Future research might focus on evaluating different types of leg pain. TRIAL REGISTRATION: Clinicaltrials.gov: 109,643.

Using feedback on patient health outcomes to improve orthopaedic physical therapist practice: a quality improvement study.

OBJECTIVE: Measuring health outcomes plays an important role in patient-centred healthcare. When aggregated across patients, outcomes can provide data for quality improvement (QI). However, most physical therapists are not familiar with QI methods based on patient outcomes. This mixed-methods study aimed to develop and evaluate a QI programme in outpatient physical therapy care based on routinely collected health outcomes of patients with low-back pain and neck pain. METHODS: The QI programme was conducted by three teams of 5-6 physical therapists from outpatient settings. Plan-do-study-act cycles were used based on team-selected goals. Monthly feedback reports of process and outcomes of care, including pre-post treatment changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI), guided the QI efforts. Primary outcomes were pre-QI and post-QI changes in knowledge and attitudes towards outcome measures through a survey, and administered and self-reported compliance with using the ODI and NDI. Semistructured interviews and a focus group were conducted to evaluate the perceived value of the programme. RESULTS: Post-QI, the survey showed improvements in two items related to the role of patients and implementation of outcome measures. Registered pre-QI and post-QI completion rates were high at intake (ODI:91% pre, 88% post; NDI:75% pre, 84% post), while completion rates at discharge improved post-QI (ODI:14% pre, 66% post; NDI: 32% pre, 50% post). Perceived benefits of the QI programme included clinician and institutional accountability to processes and strategies aimed at continuous improvement in patient care. An important facilitator for programme participation was autonomy in project selection and development, while a main barrier was the time required to set up the QI project. CONCLUSION: A QI programme based on the feedback of routinely collected health outcomes of patients with low back pain and neck pain was feasible and well accepted by three pilot teams of physical therapists.

Evaluating the implementation of personalised outcomes forecasts to optimise supervised exercise therapy in patients with intermittent claudication in the Netherlands: a multimethods study.

BACKGROUND: To support the optimisation of supervised exercise therapy (SET) in patients with intermittent claudication, we developed personalised outcomes forecasts (POFs), which visualise estimated walking distance and quality of life for individual patients. The POFs may enable healthcare professionals, such as physical and exercise therapists, to improve shared decision-making and patient outcomes. OBJECTIVES: To assess differences in patient outcomes (functional walking distance, maximal walking distance and health-related quality of life) and the level of shared decision-making before and after the implementation of POFs in the conservative treatment of patients with intermittent claudication. METHODS: An interrupted time series design was used to compare preimplementation and postimplementation differences on patient outcomes. Using routinely collected data, differences from baseline to 6 months were compared between patients before and patients after the implementation. To compare levels of shared decision-making, we conducted observations of initial consults within a sample of physical or exercise therapists both before and after the implementation. Audiorecords of observations were scored on shared decision-making using the OPTION-5 instrument. RESULTS: Differences in improvements between patients with whom POFs were discussed (n=317) and patients before the implementation of POFs (n=721) did not reach statistical significance for both functional walking distance (experimental vs. control=+23%, p=0.11) and maximal walking distance (experimental vs. control=+21%, p=0.08). For health-related quality of life, the POFs-informed patients showed a statistically significant greater improvement of 4% (p=0.04). Increased levels of shared decision-making were observed in postimplementation consults (n=20) when compared with preimplementation consults (n=36), as the median OPTION-5 total score showed a statistically significant increase from 45 to 55 points (p=0.01). CONCLUSIONS: Integrating POFs into daily practice of SET for patients with intermittent claudication could assist in improving health-related quality of life and enhancing patient involvement. Using POFs did not result in statistically significant different improvements between groups on walking distances. TRIAL REGISTRATION NUMBER: NL8838.

Nurturing the Seeds of Participation: Unveiling the Foundational Path for Understanding Aging in Place Barriers and Facilitators From the Perspective of Older Adults Using Mixed Methods and Translational Science.

Participation in society is a cornerstone for quality of life, active aging, and aging in place. While the majority of older adults prefer aging in place, health and financial challenges can hinder this vision. Conducted in suburban South Jersey, this study utilized mixed methods, including surveys and interviews with older adult participants. Surveys indicated that satisfaction with participation in the community is influenced by functional ability, healthcare service availability, and information access. Interviewees identified suggestions to overcome barriers (e.g., improve access to community and address ageism). Combined results provide a theory of change which suggests older adults' empowerment in community participation hinges on home living support, participation options aligning with ability and interest, and accessible information on community events. This person-centered planning approach emphasizes the importance of older adult and stakeholder participation in foundational community planning, offering translational foundational tools for evidence-based strategies to engage them in future community action plans (CAPs).

Best practice recommendations for speech-language pathology in children with neuromuscular disorders: A Delphi-based consensus study.

PURPOSE: Speech-language pathology (SLP) is considered an essential intervention due to the high prevalence of dysphagia and dysarthria in paediatric neuromuscular disorders (pNMD). Evidence-based guidelines for SLP in pNMD are missing and children could be deprived the best of care. This study aimed to achieve consensus and present best practice recommendations on SLP intervention in pNMD. METHOD: A modified Delphi technique was used with a panel of experienced Dutch speech-language pathologists. In two online survey rounds and a face-to-face consensus meeting, the SLP experts proposed intervention items for cases of four types of pNMD (congenital myopathy, Duchenne muscular dystrophy, myotonic dystrophy type 1, and spinal muscular atrophy type 2), covering symptoms of dysphagia, dysarthria, drooling, and oral hygiene problems. They rated the level of agreement. RESULT: Intervention items that achieved consensus were incorporated into best practice recommendations. These recommendations cover six core intervention components (wait and see, explanation and advice, training and treatment, aids and adjustments, referral to other disciplines, and monitoring) suitable for the described symptoms. CONCLUSION: Insight into treatment options is essential to facilitate speech-language pathologists in clinical decision-making. The current study led to best practice recommendations for speech-language pathologists working within the field of pNMD.

Barriers and facilitators of meaningful patient participation at the collective level in healthcare organizations: A systematic review.

INTRODUCTION: Collective patient participation, such as patient participation in policy making, has become increasingly important to achieve high-quality care. However, there is little knowledge on how to let patients participate in a meaningful manner at this level. The aim of this systematic literature review was to provide an overview of barriers, facilitators, and associated impact of collective patient participation. METHODS: PubMed and EMBASE were searched until May 2023 for studies that evaluated collective patient participation. Study characteristics, methods for patient participation, barriers and facilitators, and impact (if measured) of patient participation were extracted from the articles. RESULTS: We included 59 articles. Identified barriers and facilitators of collective patient participation were grouped into five categories: (1) preconditions for patient participation, (2) strategy for patient participation, (3) preparation of patients and staff for patient participation, (4) support for patients and staff during patient participation, and (5) evaluation of patient participation. Impact of patient participation was reported in 34 included studies at three levels: quality of care and research, the team and organization, and the participants themselves. Only three studies reported quantitative outcomes. CONCLUSION: Interestingly, similar challenges were experienced during a period of twenty years, indicating that little progress has been made in structuring patient participation. Our overview of barriers and facilitators will therefore help to improve and structure collective patient participation.

Evaluation of Primary Allied Health Care in Patients Recovering From COVID-19 at 6-Month Follow-up: Dutch Nationwide Prospective Cohort Study.

BACKGROUND: Patients recovering from COVID-19 often experience persistent problems in their daily activities related to limitations in physical, nutritional, cognitive, and mental functioning. To date, it is unknown what treatment is needed to support patients in their recovery from COVID-19. OBJECTIVE: This study aimed to evaluate the primary allied health care of patients recovering from COVID-19 at 6-month follow-up and to explore which baseline characteristics are associated with changes in the scores of outcomes between baseline and 6-month follow-up. METHODS: This Dutch nationwide prospective cohort study evaluated the recovery of patients receiving primary allied health care (ie, dietitians, exercise therapists, occupational therapists, physical therapists, and speech and language therapists) after COVID-19. All treatments offered by primary allied health professionals in daily practice were part of usual care. Patient-reported outcome measures on participation, health-related quality of life, fatigue, physical functioning, and psychological well-being were assessed at baseline and at 3- and 6-month follow-up. Linear mixed model analyses were used to evaluate recovery over time, and uni- and multivariable linear regression analyses were used to examine the association between baseline characteristics and recovery. RESULTS: A total of 1451 adult patients recovering from COVID-19 and receiving treatment from 1 or more primary allied health professionals were included. For participation (Utrecht Scale for Evaluation of Rehabilitation-Participation range 0-100), estimated mean differences of at least 2.3 points were observed at all time points. For the health-related quality of life (EuroQol Visual Analog Scale, range 0-100), the mean increase was 12.3 (95% CI 11.1-13.6) points at 6 months. Significant improvements were found for fatigue (Fatigue Severity Scale, range 1-7): the mean decrease was -0.7 (95% CI -0.8 to -0.6) points at 6 months. However, severe fatigue was reported by 742/929 (79.9%) patients after 6 months. For physical functioning (Patient-Reported Outcomes Measurement Information System-Physical Function Short Form 10b, range 13.8-61.3), the mean increase was 5.9 (95% CI 5.9-6.4) points at 6 months. Mean differences of -0.8 (95% CI -1.0 to -0.5) points for anxiety (Hospital Anxiety and Depression Scale range 0-21) and -1.6 (95% CI -1.8 to -1.3) points for depression were found after 6 months. A worse baseline score, hospital admission, and male sex were associated with greater improvement between baseline and 6-month follow-up, whereas age, the BMI, comorbidities, and smoking status were not associated with mean changes in any outcome measures. CONCLUSIONS: Patients recovering from COVID-19 who receive primary allied health care make progress in recovery but still experience many limitations in their daily activities after 6 months. Our findings provide reference values to health care providers and health care policy makers regarding what to expect from the recovery of patients who receive health care from 1 or more primary allied health professionals. TRIAL REGISTRATION: ClinicalTrials.gov NCT04735744; https://tinyurl.com/3vf337pn. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2340/jrm.v54.2506.

Work-focused healthcare from the perspective of employees living with cardiovascular disease: a patient experience journey mapping study.

BACKGROUND: People living with cardiovascular diseases (CVD) often experience work participation problems. Good work-focused healthcare, defined as the received advice, treatment, and guidance focusing on work participation, can support the patient and work place. However, experiences with work-focused healthcare are generally not always positive which is a barrier for work participation. Therefore, the objective of this study is to gain insight into the work-focused healthcare journey from the perspective of patients with work participation problems due to CVD, to understand their experiences and needs, and to derive opportunities for improving work-focused healthcare service at a system level. METHODS: Semi-structured interviews, preceded by preparatory assignments, were conducted with 17 patients who experience(d) work participation problems due to CVD. The patient experience journey map (PEJM) approach was used to visualize the patients' work-focused healthcare journey, including experiences and needs over time and place, from which opportunities to improve work-focused healthcare from the patient's perspective were derived. RESULTS: An aggregated PEJM consisting of six phases was composed and graphically mapped. The first phase, working, represents a period in which CVD health problems and subsequent functional limitations occur. The next two phases, short- and long-term sick leave, represent a period of full sick leave. The last three phases, start-, partial-, and full vocational reintegration, focus on the process of return to work that takes place ranging from a few months up to several years after sick-listing. For each phase the touchpoints, timespan, stakeholders, activities, experiences and needs from the perspective of the patients were identified. Finally, for better work-focused healthcare nine opportunities for improvement were derived from the PEJM, e.g. emphasize the need for work adjustment prior to the medical intervention, provide more personalized advice on handling work limitations, and putting more compelling pressure on the employer to create suitable work positions for their employees. DISCUSSION/CONCLUSION: This paper contributes insights to provide a more patient-centered work-focused healthcare trajectory for patients employed in paid jobs when living with CVD. The PEJM provides an understanding of the patients' perspectives throughout their work-focused healthcare journey and highlights opportunities for improvement towards a better suited and seamless patient journey, Although this research was conducted within the Dutch healthcare system, it can be assumed that the findings on integrated work-focused healthcare are largly transferable to other healthcare systems.

Functional outcomes after reverse shoulder megaprosthesis following resection of malignant bone tumor in the proximal humerus: a systematic review and meta-analysis.

After resection of tumors in the proximal humerus, orthopedic oncologic surgeons are able to restore the shoulder function of patients with reverse shoulder megaprosthesis. Information about expected postoperative physical functioning is required to guide patient expectations, identify abnormal recovery, and set treatment goals. The aim was to provide an overview of functional outcomes after reverse shoulder megaprosthesis in patients after proximal humerus resection. This systematic review searched studies in MEDLINE, CINAHL, and Embase up to March 2022. Data on performance-based and patient-reported functional outcomes were extracted using standardized data extraction files. A meta-analysis with random effects model was performed to estimate outcomes after 2-year follow-up. The search identified 1089 studies. Nine studies were included in the qualitative analysis and six in the meta-analysis. Forward flexion range of motion (ROM) after 2 years was 105 degrees (95% Confidence Interval [CI]: 88-122, n = 59), abduction ROM 105 degrees (95% CI: 96-115, n = 29), and external rotation ROM 26 degrees (95% CI: 1-51, n = 48). The mean American Shoulder and Elbow Surgeons score after 2 years was 67 points (95% CI: 48-86, n = 42), mean Constant-Murley-Score 63 (95% CI: 62-64, n = 36), and mean Musculoskeletal Tumor Society score 78 (95% CI: 66-91, n = 56). The meta-analysis shows acceptable functional outcomes 2 years after reverse shoulder megaprosthesis. However, outcomes may well differ between patients as reflected by the CIs. Further research should focus on modifiable factors associated with impaired functional outcomes.

Nationwide implementation of personalized outcomes forecasts to support physical therapists in treating patients with intermittent claudication: Protocol for an interrupted time series study.

INTRODUCTION: Shared decision-making is the cornerstone of patient-centered care. However, evidence suggests that the application of shared decision-making in physical therapy practice is limited. To elicit shared decision-making and thereby potentially improve patient outcomes for patients with intermittent claudication, we developed a decision support system. This decision support system provides personalized outcomes forecasts that visualize the estimated walking distance of an individual patient. We hypothesize that personalized outcomes forecasts can support physical therapists in personalizing care to the needs and priorities of the individual patient to improve therapy outcomes. RESEARCH OBJECTIVES: The primary aim is to evaluate the impact of personalized outcomes forecasts for patients with intermittent claudication to optimize personalized treatment. Second, this study aims to evaluate the process of implementation. METHODS: This study uses a prospective interrupted time series (ITS) design. Participating physical therapists are divided into four clusters. Every month of the study period, a new cluster will be invited to begin using the decision support system. We aim to include data of 11,250 newly referred patients for physical therapy treatment. All therapists associated with a network of specialized therapists (Chronic CareNet) and patients treated by these therapists are eligible to participate. The decision support system, called the KomPas, makes use of personalized outcomes forecasts, which visualize the estimated outcome of supervised exercise therapy for an individual patient with intermittent claudication. Personalized outcomes forecasts are developed using a neighbors-based approach that selects patients similar to the index patient (a.k.a. neighbors) from a large database. Outcomes to evaluate impact of implementation are patients' functional and maximal walking distance, quality of life and shared decision-making. Process evaluation will be measured in terms of utilization efficacy, including the outcomes dropout rate and reasons to (not) use the personalized outcomes forecasts. Data will be routinely collected through two online systems: the Chronic CareNet Quality system, and the website logs of the decision support system. Additionally, observations and semi-structured interviews will be conducted with a small subset of therapists. ETHICS: Formal medical ethical approval by the Medical Research Ethics Committees United 'MEC-U' was not required for this study under Dutch law (reference number 2020-6250).

Online monitoring of focal spasticity treatment with botulinum toxin in people with chronic stroke or hereditary spastic paraplegia: a feasibility study.

OBJECTIVE: To investigate the feasibility and usability of an online spasticity monitoring tool amongst people with hereditary spastic paraplegia or chronic stroke receiving botulinum toxin treatment, and their healthcare providers. METHODS: Mixed methods cohort study, measuring recruitment success and adherence to the monitoring in 3 rehabilitation institutions. In addition, the System Usability Scale (SUS) and interviews with patients and their healthcare providers were used for quantitative and qualitative analysis, respectively. A deductive directed content analysis was used for qualitative evaluation. RESULTS: Of the 19 persons with hereditary spastic paraplegia and 24 with stroke who enrolled in the study, recruitment success and adherence were higher amongst people with hereditary spastic paraplegia compared with stroke. Usability was found "marginal" by rehabilitation physicians and "good" by patients and physical therapists (SUS scores 69, 76, and 83, respectively). According to all participant groups, online monitoring potentially contributes to spasticity management if it is tailored to the actual needs and capabilities of patients, and if it can easily be integrated into the daily/working routines of all users. CONCLUSION: Online monitoring of spasticity in people with hereditary spastic paraplegia or stroke receiving treatment with botulinum toxin may be feasible, provided that the monitoring tool is tailored to the needs of all users.

Outcomes in pulmonary sarcoidosis: results of a newly implemented prednisone protocol.

Background and aim Prednisone is used as first-line therapy for patients with pulmonary sarcoidosis. There is however no clear association between prednisone dose and FVC change in patients with pulmonary sarcoidosis. In order to improve our standard of care we introduced a more conservative prednisone protocol. Methods This study is a single centre observational study, applying value-based healthcare (VBHC) and quality improvement (QI) principles. Prednisone intake was reduced from a starting dose of 40 mg to a starting dose of 20 mg. Primary outcomes evaluated were FVC, FEV1 and DLCO % predicted. The secondary outcome measure was BMI. Results 369 patients were included in the old-cohort and 215 in the new-cohort. In the old-cohort, 182 (49.0%) of the patients were treated with prednisone. In total, 114 patients (62.6%) were treated according to the old protocol with a mean initial prednisone dose of 32.1 ±14.2 mg. In the new-cohort, 93 patients (45.0%) were treated with prednisone of which 53 patients (57.0%) received prednisone according to the new protocol. The mean initial prednisone dose in the new-cohort was 21.4 ±9.8 mg. Changes in FVC and FEV1 % predicted did not vary. Change in % predicted DLCO was 2.4 ±9.3 for the old-cohort and -1.3 ±11.4 for the new-cohort (p = 0.01). No statistically significant changes in BMI were observed. Conclusions Our results indicate that in more than half of the patients the new protocol was followed. Data support the observation that a more conservative prednisone regimen might be equally effective, looking at changes in pulmonary function and BMI.

External Validation of Prediction Models for Surgical Complications in People Considering Total Hip or Knee Arthroplasty Was Successful for Delirium but Not for Surgical Site Infection, Postoperative Bleeding, and Nerve Damage: A Retrospective Cohort Study.

Although several models for the prediction of surgical complications after primary total hip or total knee replacement (THA and TKA, respectively) are available, only a few models have been externally validated. The aim of this study was to externally validate four previously developed models for the prediction of surgical complications in people considering primary THA or TKA. We included 2614 patients who underwent primary THA or TKA in secondary care between 2017 and 2020. Individual predicted probabilities of the risk for surgical complication per outcome (i.e., surgical site infection, postoperative bleeding, delirium, and nerve damage) were calculated for each model. The discriminative performance of patients with and without the outcome was assessed with the area under the receiver operating characteristic curve (AUC), and predictive performance was assessed with calibration plots. The predicted risk for all models varied between <0.01 and 33.5%. Good discriminative performance was found for the model for delirium with an AUC of 84% (95% CI of 0.82-0.87). For all other outcomes, poor discriminative performance was found; 55% (95% CI of 0.52-0.58) for the model for surgical site infection, 61% (95% CI of 0.59-0.64) for the model for postoperative bleeding, and 57% (95% CI of 0.53-0.61) for the model for nerve damage. Calibration of the model for delirium was moderate, resulting in an underestimation of the actual probability between 2 and 6%, and exceeding 8%. Calibration of all other models was poor. Our external validation of four internally validated prediction models for surgical complications after THA and TKA demonstrated a lack of predictive accuracy when applied in another Dutch hospital population, with the exception of the model for delirium. This model included age, the presence of a heart disease, and the presence of a disease of the central nervous system as predictor variables. We recommend that clinicians use this simple and straightforward delirium model during preoperative counselling, shared decision-making, and early delirium precautionary interventions.

A framework to improve quality of hospital-based physiotherapy: a design-based research study.

BACKGROUND: A quality framework for hospital-based physiotherapy is lacking. This study aims to design a framework, building on the currently available literature, to improve the quality of hospital-based physiotherapy. METHODS: A multidisciplinary panel of six representatives of hospital-based physiotherapy and their key stakeholders (patients, medical specialists, hospital management and professional association) was set up. We used brainwriting to sample ideas and the 'decision-matrix' to select the best ideas. RESULTS: The first round of brainwriting with an online panel of six experienced participants yielded consensus on seven possible methods for quality improvement of hospital-based physiotherapy [1]: continuing education [2] ,feedback on patient reported experience measures and patient reported outcome measures [3] ,a quality portfolio [4] ,peer observation and feedback [5] ,360 degree feedback [6] ,a management information system, and [7] intervision with intercollegiate evaluation. Placing these methods in a decision matrix against four criteria (measurability, acceptability, impact, accessibility) resulted in a slight preference for a management information system, with almost equal preference for five other methods immediately thereafter. The least preference was given to a 360-degree feedback. CONCLUSIONS: In the design of a framework for improving the quality of hospital-based physiotherapy, all seven suggested methods were perceived as relevant but differed in terms of advantages and disadvantages. This suggests that, within the framework, a mixture of these methods may be desirable to even out respective advantages and disadvantages.

Predicting readiness for return to sport and performance after anterior cruciate ligament reconstruction rehabilitation.

BACKGROUND: Determining readiness to return to sport after anterior cruciate ligament (ACL) reconstruction is challenging. OBJECTIVES: To develop models to predict initial (directly after rehabilitation) and sustainable (one year after rehabilitation) return to sport and performance in individuals after ACL reconstruction. METHODS: We conducted a multicentre, prospective cohort study and included 208 participants. Potential predictors - demographics, pain, effusion, knee extension, muscle strength tests, jump tasks and three sport-specific questionnaires - were measured at the end of rehabilitation and 12 months post discharge from rehabilitation. Four prediction models were developed using backward logistic regression. All models were internally validated by bootstrapping. RESULTS: All 4 models shared 3 predictors: the participant's goal to return to their pre-injury level of sport, the participant's psychological readiness and ACL injury on the non-dominant leg. Another predictor for initial return to sport was no knee valgus, and, for sustainable return to sport, the single-leg side hop. Bootstrapping shrinkage factor was between 0.91 and 0.95, therefore the models' properties were similar before and after internal validation. The areas under the curve of the models ranged from 0.74 to 0.86. Nagelkerke's R2 varied from 0.23 to 0.43 and the Hosmer-Lemeshow test results varied from 2.7 (p = 0.95) to 8.2 (p = 0.41). CONCLUSION: Initial and sustainable return to sport and performance after anterior cruciate ligament reconstruction rehabilitation can be easily predicted by the sport goal formulated by the individual, the individual's psychological readiness, and whether the affected leg is the dominant or non-dominant leg.

The GIN-McMaster guideline tool extension for the integration of quality improvement and quality assurance in guidelines: a description of the methods for its development.

BACKGROUND AND OBJECTIVES: Our objective was to develop an extension of the widely used GIN-McMaster Guideline Development Checklist and Tool for the integration of quality assurance and improvement (QAI) schemes with guideline development. METHODS: We used a mixed-methods approach incorporating evidence from a systematic review, an expert workshop and a survey of experts to iteratively create an extension of the checklist for QAI through three rounds of feedback. As a part of this process, we also refined criteria of a good guideline-based quality indicator. RESULTS: We developed a 40-item checklist extension addressing steps for the integration of QAI into guideline development across the existing 18 topics and created one new topic specific to QAI. The steps span from 'organization, budget, planning and training', to updating of QAI and guideline implementation. CONCLUSION: The tool supports integration of QAI schemes with guideline development initiatives and it will be used in the forthcoming integrated European Commission Initiative on Colorectal Cancer. Future work should evaluate this extension and QAI items requiring additional support for guideline developers and links to QAI schemes.

Enhancing the role of the social network in activity (re)engagement post-stroke: a focus group study with rehabilitation professionals.

BACKGROUND: People post-stroke are at risk of not being able to participate in valued activities. It is important that rehabilitation professionals prepare people post-stroke for the transition home and provide needed support when they live at home. Several authors have suggested that members of the broad social network should play an active role in rehabilitation. This includes informing them about the importance of activity (re)engagement post-stroke and learning strategies to provide support. It is not clear when and how the broad social network can best be equipped to provide adequate activity support. This study aimed to explore stroke professionals' perspectives on strategies that establish a social network that supports activity (re)engagement of people post-stroke, when strategies are best implemented, and the factors that influence the implementation of these strategies. METHODS: Two focus groups were executed. Content analysis was used to analyze the transcripts of the recorded conversations. RESULTS: Eighteen professionals with various professional backgrounds and roles in treating people post-stroke participated. Strategies to establish a supportive social network included identifying, expanding, informing, and actively engaging network members. Working with the network in the immediate post-stroke phase was regarded as important for improving long-term activity outcomes. Participants expressed that most strategies to equip the social network to support people post-stroke need to take place within community care. However, the participants experienced difficulties in implementing network strategies. Perceived barriers included interprofessional collaboration, professional knowledge, self-efficacy, and financial structures. CONCLUSIONS: Strategies to involve the social network of people post-stroke are not fully implemented. Although identifying members of a social network should begin during inpatient rehabilitation, the main part of actively engaging the network will have to take place when the people post-stroke return home. Implementing social network strategies requires a systematic process focusing on collaboration, knowledge, attitude, and skill development.

Implementing a Personalized Physical Therapy Approach (Coach2Move) Is Effective in Increasing Physical Activity and Improving Functional Mobility in Older Adults: A Cluster-Randomized, Stepped Wedge Trial.

OBJECTIVE: The purpose of this study was to assess whether the superior cost-effectiveness of a personalized physical therapy approach (Coach2Move)-which was demonstrated in a previous trial compared with usual care physical therapy (UCP)-can be replicated in daily clinical practice. METHODS: A multicenter, cluster-randomized, stepped wedge trial with 4 clusters consisting of 4 physical therapist practices in the Netherlands was used to compare a personalized physical therapy approach to elicit physical activity (Coach2Move) versus care as usual. Multilevel analyses for effectiveness were conducted for the amount of physical activity (Longitudinal Aging Study Amsterdam Physical Activity Questionnaire) and functional mobility (Timed "Up & Go" Test) at 3, 6 (primary outcome), and 12 months' follow-up. Secondary outcomes were level of frailty (Evaluative Frailty Index for Physical Activity), perceived effect (Global Perceived Effect and Patient-Specific Complaints Questionnaires), quality of life (Euro Quality of Life-5 Dimensions-5 Levels [EQ-5D-5L]), and health care expenditures. RESULTS: The 292 community-dwelling older adults with mobility problems visiting physical therapists were included in either the Coach2Move (n = 112; mean [SD] age = 82 [5] years; 60% female) or UCP (n = 180; mean [SD] age = 81 (6) years; 62% female) section of the trial. At baseline, Coach2Move participants were less physically active compared with UCP participants (mean difference = -198; 95% CI = -90 to -306 active minutes). At 6 months, between-group mean differences [95% CI] favored Coach2Move participants on physical activity levels (297 [83 to 512] active minutes), functional mobility (-14.2 [-21 to -8]) seconds), and frailty levels (-5 [-8 to -1] points). At 12 months, the physical activity levels of Coach2Move participants further increased, and frailty levels and secondary outcomes remained stable, whereas outcomes of UCP participants decreased. After the Coach2Move implementation strategy, physical therapists utilized significantly fewer treatment sessions compared with before the implementation (15 vs 22). Anticipated cost savings were not observed. CONCLUSION: This study replicated the results of an earlier trial and shows that Coach2Move leads to better mid- and long-term outcomes (physical activity, functional mobility, level of frailty) in fewer therapy sessions compared with UCP. Based on these and earlier findings, the implementation of Coach2Move in physical therapist practice is recommended. IMPACT: This article describes the implementation of the Coach2Move approach, a treatment strategy that has proven to be cost-effective in a previously conducted randomized controlled trial. Implementation of Coach2Move in a real-life setting allowed an evaluation of the effects in a clinically relevant population. Coach2Move has been shown to increase physical activity, improve functional mobility, and reduce frailty more effectively compared with UCP therapy and therefore has application for physical therapists working with older adults in daily clinical practice. LAY SUMMARY: Coach2Move is a new physical therapy approach for older adults. Implementation of Coach2Move in daily clinical practice can help people better outcomes over a longer period of time against similar costs compared with regular physical therapy.