Implementing neurodevelopmental follow-up care for children with congenital heart disease: A scoping review with evidence mapping.

AIM: To identify and map evidence describing components of neurodevelopmental follow-up care for children with congenital heart disease (CHD). METHOD: This was a scoping review of studies reporting components of neurodevelopmental follow-up programmes/pathways for children with CHD. Eligible publications were identified through database searches, citation tracking, and expert recommendations. Two independent reviewers screened studies and extracted data. An evidence matrix was developed to visualize common characteristics of care pathways. Qualitative content analysis identified implementation barriers and enablers. RESULTS: The review included 33 studies. Twenty-one described individual care pathways across the USA (n = 14), Canada (n = 4), Australia (n = 2), and France (n = 1). The remainder reported surveys of clinical practice across multiple geographical regions. While heterogeneity in care existed across studies, common attributes included enrolment of children at high-risk of neurodevelopmental delay; centralized clinics in children's hospitals; referral before discharge; periodic follow-up at fixed ages; standardized developmental assessment; and involvement of multidisciplinary teams. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness. Multi-level stakeholder engagement and integration with other services were key drivers of success. INTERPRETATION: Defining components of effective neurodevelopmental follow-up programmes and care pathways, along with enhancing and expanding guideline-based care across regions and into new contexts, should continue to be priorities. WHAT THIS PAPER ADDS: Twenty-two different neurodevelopmental follow-up care pathways/programmes were published, originating from four countries. Twelve additional publications described broad practices for neurodevelopmental follow-up across regions Common attributes across eligibility, service structure, assessment processes, and care providers were noted. Studies reported programme acceptability, uptake, cost, and effectiveness. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness.

Navigating the challenges of imposter participants in online qualitative research: lessons learned from a paediatric health services study.

BACKGROUND: The growth in online qualitative research and data collection provides several advantages for health service researchers and participants, including convenience and extended geographic reach. However, these online processes can also present unexpected challenges, including instances of participant fraud or scam behaviour. This study describes an incident of participant fraud identified during online focus group discussions and interviews for a PhD health services research project on paediatric neurodevelopmental care. METHODS: We aimed to recruit carers of Australian children with neurodevelopmental disorders. Potential participants were recruited via a publicly available social media advert on Facebook offering $50 AUD compensation. Those who expressed interest via email (n = 254) were sent a pre-interview Qualtrics survey to complete. We identified imposters at an early stage via inconsistencies in their self-reported geographical location and that captured by the survey as well as recognition of suspicious actions before, during and after focus group discussions and interviews. RESULTS: Interest in participation was unexpectedly high. We determined that all potential participants were likely imposters, posing as multiple individuals and using different IP addresses across Nigeria, Australia, and the United States. In doing so, we were able to characterise several "red flags" for identifying imposter participants, particularly those posing as multiple individuals. These comprise a combination of factors including large volumes and strange timings of email responses, unlikely demographic characteristics, short or vague interviews, a preference for nonvisual participation, fixation on monetary compensation, and inconsistencies in reported geographical location. Additionally, we propose several strategies to combat this issue such as providing proof of location or eligibility during recruitment and data collection, examining email and consent form patterns, and comparing demographic data with regional statistics. CONCLUSIONS: The emergent risk of imposter participants is an important consideration for those seeking to conduct health services research using qualitative approaches in online environments. Methodological design choices intended to improve equity and access for the target population may have an unintended consequence of improving access for fraudulent actors unless appropriate risk mitigation strategies are also employed. Lessons learned from this experience are likely to be valuable for novice health service researchers involved in online focus group discussions and interviews.

Geographical challenges and inequity of healthcare access for high-risk paediatric heart disease.

BACKGROUND: Geographical context is an important consideration for health system design to promote equality in access to care for patients with childhood heart disease (CHD), particularly those living in regional, rural, and remote areas. To help inform future policy and practice recommendations, this study aimed to (i) describe the geographic distribution of high-risk CHD patients accessing an Australian state-wide specialist service and (ii) estimate travel time for accessing healthcare via general practitioners (primary), nearest paediatric centre (secondary) and specialist paediatric cardiac centre (tertiary). METHODS: Participants included a cohort of children (0-18 year) who accessed state-wide specialist CHD services over a 3-year period (2019-2021) in Queensland, Australia. Locations for patient residence, general practitioner, closest paediatric centre and tertiary cardiac centre were mapped using geographical information system (GIS) software (ArcGIS Online). Travel distance and times were estimated using a Google Maps Application Programming Interface (API). RESULTS: 1019 patients (median age 3.8 years) had cardiac intervention and were included in the sample. Of this cohort, 30.2% lived outside the heavily urbanised South East Queensland (SEQ) area where the tertiary centre is located. These patients travel substantially further and longer to access tertiary level care (but not secondary or primary level care) compared to those in SEQ. Median distance for patients residing outside SEQ to access tertiary care was 953 km with a travel time of 10 h 43 min. This compares to 5.5 km to the general practitioner and 20.6 km to a paediatric service (8.9 and 54 min respectively). CONCLUSION: This geographical mapping of CHD services has demonstrated a key challenge inherent in providing specialist cardiac care to children in a large state-based healthcare system. A significant proportion of high-risk patients live large distances from tertiary level care. The greater accessibility of primary care services highlights the importance of supporting primary care physicians outside metropolitan areas to acquire or build the ability and capacity to care for children with CHD. Strengthening local primary and secondary services not only has the potential to improve the outcomes of high-risk patients, but also to reduce costs and burden associated with potentially avoidable travel from regional, rural, or remote areas to access specialist CHD services.

Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis.

BACKGROUND: Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context. METHODS: Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses. RESULTS: Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective. CONCLUSION: Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.

Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review.

BACKGROUND: Computerized clinical decision support systems (CDSSs) are essential components of modern health system service delivery, particularly within acute care settings such as hospitals. Theories, models, and frameworks may assist in facilitating the implementation processes associated with CDSS innovation and its use within these care settings. These processes include context assessments to identify key determinants, implementation plans for adoption, promoting ongoing uptake, adherence, and long-term evaluation. However, there has been no prior review synthesizing the literature regarding the theories, models, and frameworks that have informed the implementation and adoption of CDSSs within hospitals. OBJECTIVE: This scoping review aims to identify the theory, model, and framework approaches that have been used to facilitate the implementation and adoption of CDSSs in tertiary health care settings, including hospitals. The rationales reported for selecting these approaches, including the limitations and strengths, are described. METHODS: A total of 5 electronic databases were searched (CINAHL via EBSCOhost, PubMed, Scopus, PsycINFO, and Embase) to identify studies that implemented or adopted a CDSS in a tertiary health care setting using an implementation theory, model, or framework. No date or language limits were applied. A narrative synthesis was conducted using full-text publications and abstracts. Implementation phases were classified according to the "Active Implementation Framework stages": exploration (feasibility and organizational readiness), installation (organizational preparation), initial implementation (initiating implementation, ie, training), full implementation (sustainment), and nontranslational effectiveness studies. RESULTS: A total of 81 records (42 full text and 39 abstracts) were included. Full-text studies and abstracts are reported separately. For full-text studies, models (18/42, 43%), followed by determinants frameworks (14/42,33%), were most frequently used to guide adoption and evaluation strategies. Most studies (36/42, 86%) did not list the limitations associated with applying a specific theory, model, or framework. CONCLUSIONS: Models and related quality improvement methods were most frequently used to inform CDSS adoption. Models were not typically combined with each other or with theory to inform full-cycle implementation strategies. The findings highlight a gap in the application of implementation methods including theories, models, and frameworks to facilitate full-cycle implementation strategies for hospital CDSSs.

Developing critical HIV health literacy: insights from interviews with priority migrant communities in Queensland, Australia.

In Australia, surveillance data establish that there are higher rates of late HIV diagnoses among heterosexual migrants from Sub-Saharan Africa and new HIV diagnoses among gay and bisexual men (GBM) from Southeast and Northeast Asia and Latin America. Together, these groups are identified as priority migrant communities in current efforts to eliminate HIV transmissions. HIV health literacy is recognised as a key means of improving access to services and health outcomes. This qualitative paper explores critical HIV health literacy among priority migrant communities in Queensland, Australia. To foreground community voices, peer researchers from priority migrant communities participated in the project design, data collection and analysis, with 20 interviews completed. The findings demonstrate how participants' engagement with HIV health information and services is highly relational and situated within the framework of sexual health and wellbeing. Participants strategically selected where to seek information and who they trusted to help them appraise this information. They further demonstrated reflective capacities in identifying the contextual barriers that inhibit the development of their HIV health literacy. The findings highlight the need for HIV health promotion strategies that embrace a sex positive approach, promote cultural change, and involve collaboration with general practitioners (GPs).

Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey.

BACKGROUND: The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice. METHODS: An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March-December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May-July 2021). RESULTS: Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR-exercise and education-were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support. CONCLUSION: Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement.

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Exploration of the methodological quality and clinical usefulness of a cross-sectional sample of published guidance about exercise training and physical activity for the secondary prevention of coronary heart disease.

BACKGROUND: Clinicians are encouraged to use guidelines to assist in providing evidence-based secondary prevention to patients with coronary heart disease. However, the expanding number of publications providing guidance about exercise training may confuse cardiac rehabilitation clinicians. We therefore sought to explore the number, scope, publication characteristics, methodological quality, and clinical usefulness of published exercise-based cardiac rehabilitation guidance. METHODS: We included publications recommending physical activity, exercise or cardiac rehabilitation for patients with coronary heart disease. These included systematically developed clinical practice guidelines, as well as other publications intended to support clinician decision making, such as position papers or consensus statements. Publications were obtained via electronic searches of preventive cardiology societies, guideline databases and PubMed, to November 2016. Publication characteristics were extracted, and two independent assessors evaluated quality using the 23-item Appraisal of Guidelines Research and Evaluation II (AGREE) tool. RESULTS: Fifty-four international publications from 1994 to 2016 were identified. Most were found on preventive cardiology association websites (n = 35; 65%) and were freely accessible (n = 50; 93%). Thirty (56%) publications contained only broad recommendations for physical activity and cardiac rehabilitation referral, while 24 (44%) contained the necessary detailed exercise training recommendations. Many were labelled as "guidelines", however publications with other titles (e.g. scientific statements) were common (n = 24; 44%). This latter group of publications contained a significantly greater proportion of detailed exercise training recommendations than clinical guidelines (p = 0.017). Wide variation in quality also existed, with 'applicability' the worst scoring AGREE II domain for clinical guidelines (mean score 53%) and 'rigour of development' rated lowest for other guidance types (mean score 33%). CONCLUSIONS: While a large number of guidance documents provide recommendations for exercise-based cardiac rehabilitation, most have limitations in either methodological quality or clinical usefulness. The lack of rigorously developed guidelines which also contain necessary detail about exercise training remains a substantial problem for clinicians.

Preferences for Neurodevelopmental Follow-Up Care for Children: A Discrete Choice Experiment.

INTRODUCTION: Identifying and addressing neurodevelopmental delays in children can be challenging for families and the healthcare system. Delays in accessing services and early interventions are common. The design and delivery of these services, and associated outcomes for children, may be improved if service provision aligns with families' needs and preferences for receiving care. The aim of this study is to identify families' preferences for neurodevelopmental follow-up care for children using an established methodology. METHODS: We used a discrete choice experiment (DCE) to elicit families' preferences. We collected data from families and caregivers of children with neurodevelopmental needs. The DCE process included four stages. In stage 1, we identified attributes and levels to be included in the DCE using literature review, interviews, and expert advice. The finalised attributes were location, mode of follow-up, out-of-pocket cost per visit, mental health counselling for parents, receiving educational information, managing appointments, and waiting time. In stage 2, we generated choice tasks that contained two alternatives and a 'neither' option for respondents to choose from, using a Bayesian d-efficient design. These choice tasks were compiled in a survey that also included demographic questions. We conducted pre- and pilot tests to ensure the functionality of the survey and obtain priors. In stage 3, the DCE survey was administered online. We received 301 responses. In stage 4, the analysis was conducted using a latent class model. Additionally, we estimated the relative importance of attributes and performed a scenario analysis. RESULTS: Two latent classes were observed. More families with full-time employees, higher incomes, postgraduate degrees, and those living in metropolitan areas were in class 1 compared with class 2. Class 1 families preferred accessing local public health clinics, face-to-face follow-up, paying AUD100 to AUD500, mental health support, group educational activities, health service-initiated appointments, and waiting < 3 months. Class 2 families disliked city hospitals when compared with private, preferred paying AUD100 or no cost, and had similar preferences regarding mental health support and wait times as class 1. However, no significant differences were noted in follow-up modality, receiving educational information, and appointment management. The relative importance estimation suggested that location was most important for class 1 (28%), whereas for class 2, cost accounted for nearly half of the importance when selecting an alternative. The expected uptake of follow-up care, estimated under three different hypothetical scenarios, may increase by approximately 24% for class 2 if an 'ideal' scenario taking into account preferences was implemented. CONCLUSION: This study offers insights into aspects that may be prioritised by health services and policymakers to improve the design and delivery of neurodevelopmental follow-up care for children. The findings may enhance the organisation and functioning of existing care programmes; and therefore, improve the long-term outcomes of children with neurodevelopmental needs and their families.

Challenges and recommendations for collecting and quantifying implementation costs in practice: a qualitative interview study.

BACKGROUND: The cost of implementation is typically not accounted for in published economic evaluations, which determine the relative value for money of health innovations and are important for allocating scarce resources. Despite key papers outlining relevant implementation costs, they continue to be under reported in the literature and often not considered in practice. This study sought to understand and outline current practices for capturing the costs associated with implementation efforts, with examples from the digital health setting. METHODS: A qualitative study of semi-structured interviews with purposefully sampled experts in implementation science, health economics and/or digital health was conducted. The interview guide was informed by a literature review and was pilot tested. Interviews were digitally recorded and transcribed. A hybrid inductive/deductive framework analysis was conducted using thematic analysis to elicit key concepts related to the research question. RESULTS: Interviews were conducted with sixteen participants with specialist expertise in implementation science (n = 8), health economics (n = 6), and/or digital health (n = 8). Five participants were experienced in more than one field. Four key themes were elicited from the data: difficulty identifying and collecting implementation cost data; variation in approaches for collecting implementation cost data; the value of implementation costs; and collaboration enables implementation costing. Broadly, while interviewees recognised implementation costs as important, only some costs were considered in practice likely due to the perceived ill-defined boundaries and inconsistencies in terminology. A variety of methods were used to collect and estimate implementation costs; the most frequent approach was staff time tracking. Multidisciplinary collaboration facilitated this process, but the burden of collecting the necessary data was also highlighted. CONCLUSIONS: In current practice, standardised methods are not commonly used for data collection or estimation of implementation costs. Improved data collection through standardised practices may support greater transparency and confidence in implementation cost estimates. Although participants had industry exposure, most were also academic researchers and findings may not be representative of non-academic industry settings.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review.

OBJECTIVES: This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes. DESIGN: Scoping review. DATA SOURCES: Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions. ELIGIBILITY CRITERIA: We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings. DATA EXTRACTION AND SYNTHESIS: Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework. RESULTS: Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework. CONCLUSIONS: Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Expanding access to telehealth in Australian cardiac rehabilitation services: a national survey of barriers, enablers, and uptake.

Aims: Cardiac rehabilitation (CR) is traditionally delivered in-person; however, the COVID-19 pandemic provided impetus for alternative offerings such as telehealth. We investigated uptake, barriers, and enablers in a national survey during the pandemic in Australia. Methods and results: We surveyed CR programmes between April and June 2021 using professional association networks. The anonymous online questionnaire addressed programme characteristics, COVID-19 impacts, and barriers to and enablers of telehealth use. Open-text responses were coded and presented as themes. In total, there were responses from 105 programmes (33% response rate). All states and geographical areas were represented. The use of every modality of telehealth care (telephone, video conferencing, text messaging, and web-based) increased significantly during and after COVID with a strong preference for telephone (85% of services). Respondents perceived video (53%) and telephone (47%) formats as safe and effective for delivering CR. The most common barriers to telehealth were difficulties conducting assessments and reduced engagement with patients. Prominent enablers were increased reach and reduced patient barriers to CR access. Conclusion: Telehealth use by CR programmes increased during the peak pandemic period. However, additional support is required to ensure that telehealth services can be maintained. There is considerable potential to increase the reach of CR by embedding telehealth into existing models of care.

Applying the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability Framework Across Implementation Stages to Identify Key Strategies to Facilitate Clinical Decision Support System Integration Within a Large Metropolitan Health Service: Interview and Focus Group Study.

BACKGROUND: Computerized clinical decision support systems (CDSSs) enhance patient care through real-time, evidence-based guidance for health care professionals. Despite this, the effective implementation of these systems for health services presents multifaceted challenges, leading to inappropriate use and abandonment over the course of time. Using the Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework, this qualitative study examined CDSS adoption in a metropolitan health service, identifying determinants across implementation stages to optimize CDSS integration into health care practice. OBJECTIVE: This study aims to identify the theory-informed (NASSS) determinants, which included multiple CDSS interventions across a 2-year period, both at the health-service level and at the individual hospital setting, that either facilitate or hinder the application of CDSSs within a metropolitan health service. In addition, this study aimed to map these determinants onto specific stages of the implementation process, thereby developing a system-level understanding of CDSS application across implementation stages. METHODS: Participants involved in various stages of the implementation process were recruited (N=30). Participants took part in interviews and focus groups. We used a hybrid inductive-deductive qualitative content analysis and a framework mapping approach to categorize findings into barriers, enablers, or neutral determinants aligned to NASSS framework domains. These determinants were also mapped to implementation stages using the Active Implementation Framework stages approach. RESULTS: Participants comprised clinical adopters (14/30, 47%), organizational champions (5/30, 16%), and those with roles in organizational clinical informatics (5/30, 16%). Most determinants were mapped to the organization level, technology, and adopter subdomains. However, the study findings also demonstrated a relative lack of long-term implementation planning. Consequently, determinants were not uniformly distributed across the stages of implementation, with 61.1% (77/126) identified in the exploration stage, 30.9% (39/126) in the full implementation stage, and 4.7% (6/126) in the installation stages. Stakeholders engaged in more preimplementation and full-scale implementation activities, with fewer cycles of monitoring and iteration activities identified. CONCLUSIONS: These findings addressed a substantial knowledge gap in the literature using systems thinking principles to identify the interdependent dynamics of CDSS implementation. A lack of sustained implementation strategies (ie, training and longer-term, adopter-level championing) weakened the sociotechnical network between developers and adopters, leading to communication barriers. More rigorous implementation planning, encompassing all 4 implementation stages, may, in a way, help in addressing the barriers identified and enhancing enablers.

"It's more than just a conversation about the heart": exploring barriers, enablers, and opportunities for improving the delivery and uptake of cardiac neurodevelopmental follow-up care.

Introduction: Surveillance, screening, and evaluation for neurodevelopmental delays is a pivotal component of post-surgical care for children with congenital heart disease (CHD). However, challenges exist in implementing such neurodevelopmental follow-up care in international practice. This study aimed to characterise key barriers, enablers, and opportunities for implementing and delivering outpatient cardiac neurodevelopmental follow-up care in Australia. Methods: an exploratory descriptive qualitative study was conducted with healthcare professionals across Australia who had lived experience of designing, implementing, or delivering neurodevelopmental care for children with CHD. Online semi-structured interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research to explore contextual influences. Interview transcripts were analysed using a rapid qualitative approach including templated summaries and hybrid deductive-inductive matrix analysis. Results: fifty-two participants were interviewed. Perceived barriers and enablers were organised into six higher-order themes: factors in the broader environmental, economic, and political context; healthcare system factors; organisational-level factors; provider factors; patient and family factors; and care model factors. The largest number of barriers occurred at the healthcare system level (service accessibility, fragmentation, funding, workforce), while service providers demonstrated the most enabling factors (interprofessional relationships, skilled teams, personal characteristics). Strategies to improve practice included building partnerships; generating evidence; increasing funding; adapting for family-centred care; and integrating systems and data. Discussion: Australia shares many similar barriers and enablers to cardiac neurodevelopmental care with other international contexts. However, due to unique geographical and health-system factors, care models and implementation strategies will require adaption to the local context to improve service provision.

Evaluating the tailored implementation of a multisite care navigation service for mental health in rural and remote Australia (The Bridging Study): protocol for a community-engaged hybrid effectiveness-implementation study.

BACKGROUND: A dramatic decline in mental health of people worldwide in the early COVID-19 pandemic years has not recovered. In rural and remote Australia, access to appropriate and timely mental health services has been identified as a major barrier to people seeking help for mental ill-health. From 2020 to 2021 a care navigation model, Navicare, was co-designed with rural and remote communities in the Greater Whitsunday Region of Central Queensland in Australia. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to design and guide multiple aspects of a multisite study, The Bridging Study, to evaluate the implementation of Navicare in Australia. METHODS: A community-engaged hybrid effectiveness-implementation study design will focus on the tailored implementation of Navicare at three new sites as well as monitoring implementation at an existing site established since 2021. Study outcomes assessed will include sustained access as the co-primary outcome (measured using access to Navicare mental health referral services) and Proctor's Implementation Outcomes of feasibility, acceptability, appropriateness, adoption, fidelity, implementation cost, and sustainability. Data collection for the implementation evaluation will include service usage data, community consultations, interviews, and workshops; analysed using mixed methods and guided by EPIS and other implementation frameworks. Pre-post effectiveness and cost-consequence study components are embedded in the implementation and sustainment phases, with comparison to pre-implementation data and value assessed for each EPIS phase using hospital, service, and resource allocation data. A scaling up strategy will be co-developed using a national roundtable forum in the final year of the study. Qualitative exploration of other aspects of the study (e.g., mechanisms of action and stakeholder engagement) will be conducted. DISCUSSION: Our study will use tailoring to local sites and a community-engaged approach to drive implementation of a mental health care navigation service in rural and remote Australia, with expected benefits to mental healthcare access. This approach is consistent with policy recommendations nationally and internationally as building blocks for rural health including the World Health Organization Framework for Action on Strengthening Health Systems to Improve Health Outcomes. TRIAL REGISTRATION: Prospectively registered on April 2, 2024, on the Australian New Zealand Clinical Trials Registry, no. ACTRN12624000382572. https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386665&isReview=true .

Implementation costs of hospital-based computerised decision support systems: a systematic review.

BACKGROUND: The importance of accurately costing implementation strategies is increasingly recognised within the field of implementation science. However, there is a lack of methodological guidance for costing implementation, particularly within digital health settings. This study reports on a systematic review of costing analyses conducted alongside implementation of hospital-based computerised decision support systems. METHODS: PubMed, Embase, Scopus and CINAHL databases were searched between January 2010 and August 2021. Two reviewers independently screened and selected original research studies that were conducted in a hospital setting, examined the implementation of a computerised decision support systems and reported implementation costs. The Expert Recommendations for Implementing Change Framework was used to identify and categorise implementation strategies into clusters. A previously published costing framework was applied to describe the methods used to measure and value implementation costs. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS: Titles and abstracts of 1836 articles were screened, with nine articles eligible for inclusion in the review. Implementation costs were most frequently reported under the 'evaluative and iterative strategies' cluster, followed by 'provide interactive assistance'. Labour was the largest implementation-related cost in the included papers, irrespective of implementation strategy. Other reported costs included consumables, durable assets and physical space, which was mostly associated with stakeholder training. The methods used to cost implementation were often unclear. There was variation across studies in the overall quality of reporting. CONCLUSIONS: A relatively small number of papers have described computerised decision support systems implementation costs, and the methods used to measure and value these costs were not well reported. Priorities for future research should include establishing consistent terminology and appropriate methods for estimating and reporting on implementation costs. TRIAL REGISTRATION: The review protocol is registered with PROSPERO (ID: CRD42021272948).

Preferences in the Design and Delivery of Neurodevelopmental Follow-Up Care for Children: A Systematic Review of Discrete Choice Experiments.

Neurodevelopmental disorders are a significant cause of morbidity. Early detection of neurodevelopmental delay is essential for timely diagnosis and intervention, and it is therefore important to understand the preferences of parents and clinicians for engaging with neurodevelopmental surveillance and follow-up care. Discrete choice experiment (DCE) may be an appropriate method for quantifying these preferences. This review systematically examined how DCEs have been designed and delivered in studies examining neurodevelopmental care of children and identified the preferred attributes that have been reported. PubMed, Embase, CINAHL, and Scopus databases were systematically searched. Studies were included if they used DCE to elicit preferences for a neurodevelopmental follow-up program for children. Two independent reviewers conducted the title and abstract and full-text screening. Risk of bias was assessed using a DCE-specific checklist. Findings were presented using a narrative synthesis. A total of 6618 records were identified and 16 papers were included. Orthogonal (n=5) and efficient (n=5) experimental designs were common. There was inconsistent reporting of design-related features. Analysis was primarily completed using mixed logit (n=6) or multinomial logit (n=3) models. Several key attributes for neurodevelopmental follow-up care were identified including social, behavioral and emotional support, therapy, waiting time, and out-of-pocket costs. DCE has been successfully used as a preference elicitation method for neurodevelopmental-related care. There is scope for improvement in the design and analysis of DCE in this field. Nonetheless, attributes identified in these studies are likely to be important considerations in the design and implementation of programs for neurodevelopmental care.

Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice.

OBJECTIVE: Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations. MATERIALS AND METHODS: A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist. RESULTS: Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups. DISCUSSION AND CONCLUSION: Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.