Search

Abstract Background Improving the quality of health care requires a range of evidence-based activities. Audit and feedback is commonly used as a quality improvement tool in the UK National Health Service [NHS]. We set out to assess whether current guidance and systematic review evidence can sufficiently inform practical decisions about how to use audit and feedback to improve quality of care. Methods We selected an important chronic disease encountered in primary care: diabetes mellitus. We identified recommendations from National Institute for Clinical Excellence (NICE) guidance on conducting audit and generated questions which would be relevant to any attempt to operationalise audit and feedback in a healthcare service setting. We explored the extent to which a systematic review of audit and feedback could provide practical guidance about whether audit and feedback should be used to improve quality of diabetes care and, if so, how audit and feedback could be optimised. Results National guidance suggests the importance of securing the right organisational conditions and processes. Review evidence suggests that audit and feedback can be effective in changing healthcare professional practice. However, the available evidence says relatively little about the detail of how to use audit and feedback most efficiently. Conclusion Audit and feedback will continue to be an unreliable approach to quality improvement until we learn how and when it works best. Conceptualising audit and feedback within a theoretical framework offers a way forward.

Question: What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines? Design: Systematic review. Participants: Physiotherapists treating any type of patients. Intervention: Single or multiple strategies to increase the implementation of physiotherapy clinical guidelines. Outcome measures: Professional practice, patient health, and cost of care. Results: Five papers reporting three cluster-randomised trials evaluated whether multifaceted strategies based on educational meetings increased the implementation of low back pain guidelines (2 trials) or whiplash guidelines (1 trial). Educational meetings were effective in increasing adherence to the following recommendations of low back pain guidelines: limiting the number of sessions (RD 0.13, 95% CI 0.03 to 0.23), using active intervention (RD 0.13, 95% CI 0.05 to 0.21), giving adequate information (RD 0.05, 95% CI 0.00 to 0.11), increasing activity level (RD 0.16, 95% CI 0.02 to 0.30), changing attitudes/beliefs about pain (RD 0.13, 95% CI 0.01 to 0.24). Educational meetings were effective in increasing adherence to the following recommendations of whiplash guidelines: reassuring the patient (RD 0.40, 95% CI 0.07 to 0.74), advising the patient to act as usual (RD 0.48, 95% CI 0.15 to 0.80), using functional outcome measures (RD 0.62, 95% CI 0.32 to 0.92). There was no evidence that patient health was improved or that the cost of care was reduced. Conclusion: This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care. These findings are comparable with results among other health professions. [ABSTRACT FROM AUTHOR]

Study Design: A systematic review within the Cochrane Collaboration Back Review Group.Objectives: To report the main results from the updated version of the Cochrane Review on bed rest for low back pain.Summary Of Background Data: There has been a growing amount of evidence showing that bed rest is not beneficial for people with low back pain. However, existing systematic reviews are unclear regarding the effects of bed rest for different types of low back pain.Methods: All randomized studies available in systematic searches up to March 2003 were included. Two reviewers independently selected trials for inclusion assessed the validity of included trials and extracted data. Investigators were contacted to obtain missing information.Results: Two new trials comparing advice to rest in bed with advice to stay active were included. There is high quality evidence that people with acute low back pain who are advised to rest in bed have a little more pain (standardized mean difference 0.22, 95% confidence interval: 0.02-0.41) and a little less functional recovery (standardized mean difference 0.29, 95% confidence interval: 0.05-0.45) than those advised to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain (standardized mean difference -0.03, 95% confidence interval: -0.24-0.18) or functional status (standardized mean difference 0.19, 95% confidence interval: -0.02-0.41) between bed rest and staying active.Conclusion: For people with acute low back pain, advice to rest in bed is less effective than advice to stay active. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active. [ABSTRACT FROM AUTHOR]

Background: Patients with knee osteoarthritis [OA] are commonly treated by physiotherapists in primary care. Measuring physiotherapy performance is important before developing strategies to improve quality. The purpose of this study was to measure physiotherapy performance in patients with knee OA by comparing clinical practice to evidence from systematic reviews.Methods: We developed a data-collection form and invited all private practitioners in Norway [n = 2798] to prospectively collect data on the management of one patient with knee OA through 12 treatment session. Actual practice was compared to findings from an overview of systematic reviews summarising the effect of physiotherapy interventions for knee OA.Results: A total of 297 physiotherapists reported their management for patients with knee OA. Exercise was the most common treatment used, provided by 98% of the physiotherapists. There is evidence of high quality that exercise reduces pain and improves function in patients with knee OA. Thirty-five percent of physiotherapists used acupuncture, low-level laser therapy or transcutaneous electrical nerve stimulation. There is evidence of moderate quality that these treatments reduce pain in knee OA. Patient education, supported by moderate quality evidence for improving psychological outcomes, was provided by 68%. Physiotherapists used a median of four different treatment modalities for each patient. They offered many treatment modalities based on evidence of low quality or without evidence from systematic reviews, e.g. traction and mobilisation, massage and stretching.Conclusion: Exercise was used in almost all treatment sessions in the management of knee OA. This practice is desirable since it is supported by high quality evidence. Physiotherapists also provide several other treatment modalities based on evidence of moderate or low quality, or no evidence from systematic reviews. Ways to promote high quality evidence into physiotherapy practice should be identified and evaluated. [ABSTRACT FROM AUTHOR]

Question: In patients with acute low-back pain or sciatica, does bed rest reduce pain and improve function? Data sources: Studies were identified by searching databases, including the Cochrane Controlled Trials Register, Medline (to 1998), Embase/Excerpta Medica (to 1998), Sport (to 1998), and Scisearch (to 1998); by scanning reference lists of articles; and by contacting authors. Study selection: 2 reviewers independently selected studies that were randomized or quasi-randomized trials of bed rest for persons between 16 and 80 years of age who had acute low-back pain with radiation of pain below the knee (sciatica) or no radiation of pain. Exclusion criteria were inflammatory joint disease, infection, neoplasm, metastasis, osteoporosis, and fracture. Data extraction: 2 reviewers independently assessed the quality of the study methods. A third reviewer resolved any disagreement. Data on participant characteristics, interventions, and outcomes were extracted. Authors were contacted for any missing data. Results: 9 studies (3 in North America and 6 in Europe) involving a total of 1435 patients met the selection criteria. 2 of 3 heterogeneous studies comparing the effects of bed rest with those of maintaining activity had high-quality methods, and the pooled results showed no difference in pain intensity in the short term (≤3 weeks) or the intermediate term (3 to 12 weeks) (table). The pooled results of 3 studies showed a slight decrease in functional status (Oswestry Low Back Pain Disability Questionnaire) for the bed-rest group in the short term (P < 0.01); the difference was not statistically significant in the intermediate term (table). In 2 studies comparing shorter periods (2 to 4 days) with longer periods (>4 days) of bed rest, no differences existed between groups for pain intensity, functional status, or time to recovery in the short or intermediate term. Of 4 studies that examined other treatments, 2 compared bed rest with exercise and found no... [ABSTRACT FROM AUTHOR]

Probiotics are known for their positive effects on the gut microbiota. There is growing evidence that the infant gut and skin colonization have a role in the development of the immune system, which may be helpful in the prevention and treatment of atopic dermatitis. This systematic review focused on evaluating the effect of single-strain probiotic lactobacilli consumption on treating children's atopic dermatitis. Seventeen randomized placebo-controlled trials with the primary outcome of the Scoring Atopic Dermatitis (SCORAD) index were included in the systematic review. Clinical trials using single-strain lactobacilli were included. The search was conducted until October 2022 using PubMed, ScienceDirect, Web of Science, Cochrane library and manual searches. The Joanna Briggs Institute appraisal tool was used to assess the quality of the included studies. Meta-analyses and sub meta-analyses were performed using Cochrane Collaboration methodology. Due to different methods of reporting the SCORAD index, only 14 clinical trials with 1124 children were included in the meta-analysis (574 in the single-strain probiotic lactobacilli group and 550 in the placebo group) and showed that single-strain probiotic lactobacilli statistically significantly reduced the SCORAD index compared to the placebo in children with atopic dermatitis (mean difference [MD]: -4.50; 95% confidence interval [CI]: -7.50 to -1.49; Z = 2.93; p = 0.003; heterogeneity I 2 = 90%). The subgroup meta-analysis showed that strains of Limosilactobacillus fermentum were significantly more effective than strains of Lactiplantibacillus plantarum , Lacticaseibacillus paracasei or Lacticaseibacillus rhamnosus . A longer treatment time and younger treatment age statistically significantly reduced symptoms of atopic dermatitis. The result of this systematic review and meta-analysis shows that certain single-strain probiotic lactobacilli are more successful than others in reducing atopic dermatitis severity in children. Therefore, careful consideration to strain selection, treatment time and the age of the treated patients are important factors in enhancing the effectiveness of reducing atopic dermatitis in children when choosing probiotic single-strain lactobacilli.

Background: Several studies have documented the production of wasteful research, defined as research of no scientific importance and/or not meeting societal needs. We argue that this redundancy in research may to a large degree be due to the lack of a systematic evaluation of the best available evidence and/or of studies assessing societal needs., Objectives: The aim of this scoping review is to (A) identify meta-research studies evaluating if redundancy is present within biomedical research, and if so, assessing the prevalence of such redundancy, and (B) to identify meta-research studies evaluating if researchers had been trying to minimise or avoid redundancy., Eligibility Criteria: Meta-research studies (empirical studies) were eligible if they evaluated whether redundancy was present and to what degree; whether health researchers referred to all earlier similar studies when justifying and designing a new study and/or when placing new results in the context of earlier similar trials; and whether health researchers systematically and transparently considered end users' perspectives when justifying and designing a new study., Sources of Evidence: The initial overall search was conducted in MEDLINE, Embase via Ovid, CINAHL, Web of Science, Social Sciences Citation Index, Arts & Humanities Citation Index, and the Cochrane Methodology Register from inception to June 2015. A 2nd search included MEDLINE and Embase via Ovid and covered January 2015 to 26 May 2021. No publication date or language restrictions were applied., Charting Methods: Charting methods included description of the included studies, bibliometric mapping, and presentation of possible research gaps in the identified meta-research., Results: We identified 69 meta-research studies. Thirty-four (49%) of these evaluated the prevalence of redundancy and 42 (61%) studies evaluated the prevalence of a systematic and transparent use of earlier similar studies when justifying and designing new studies, and/or when placing new results in context, with seven (10%) studies addressing both aspects. Only one (1%) study assessed if the perspectives of end users had been used to inform the justification and design of a new study. Among the included meta-research studies evaluating whether redundancy was present, only two of nine health domains (medical areas) and only two of 10 research topics (different methodological types) were represented. Similarly, among the included meta-research studies evaluating whether researchers had been trying to minimise or avoid redundancy, only one of nine health domains and only one of 10 research topics were represented., Conclusions That Relate to the Review Questions and Objectives: Even with 69 included meta-research studies, there was a lack of information for most health domains and research topics. However, as most included studies were evaluating across different domains, there is a clear indication of a high prevalence of redundancy and a low prevalence of trying to minimise or avoid redundancy. In addition, only one meta-research study evaluated whether the perspectives of end users were used to inform the justification and design of a new study., Systematic Review Registration: Protocol registered at Open Science Framework: https://osf.io/3rdua/ (15 June 2021)., (© 2022. The Author(s).)

Objectives: Higher education institutions all over the world struggled to balance the need for infection control and educational requirements, as they prepared to reopen after the first wave of the COVID-19 pandemic. A particularly difficult choice was whether to offer for in-person or online teaching. Norwegian universities and university colleges opted for a hybrid model when they reopened for the autumn semester, with some students being offered more in-person teaching than others. We seized this opportunity to study the association between different teaching modalities and COVID-19 risk, quality of life (subjective well-being), and teaching satisfaction., Study Design: Prospective, observational cohort study., Methods: We recruited students in higher education institutions in Norway who we surveyed biweekly from September to December in 2020., Results: 26 754 students from 14 higher education institutions provided data to our analyses. We found that two weeks of in-person teaching was negatively associated with COVID-19 risk compared to online teaching, but the difference was very uncertain (-22% relative difference; 95% CI -77%-33%). Quality of life was positively associated with in-person teaching (3%; 95% CI 2%-4%), as was teaching satisfaction (10%; 95% CI 8%-11%)., Conclusion: The association between COVID-19 infection and teaching modality was highly uncertain. Shifting from in-person to online teaching seems to have a negative impact on the well-being of students in higher education., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:, (© 2021 The Author(s).)

This paper describes a model developed by an interdisciplinary team of research and public engagement specialists, with backgrounds in health and social care research, higher education, evidence-based practice, leadership, commissioning research and public involvement and engagement. The model we propose combines evidence-based practice, evidence-based research, public involvement and needs led research. Our aim is to capitalise on the joining of the rationale and methods for these approaches, which have all been highlighted as important, but for which there has been a lack of models for integration. Our ambition is to argue for and show an effective and evidence-based way of working that bridges health and social care needs identification, evidence-based practice and research., (© 2021. The Author(s).)

Competing Interests: Competing interests: None declared.

Background: Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery., Objective: This study aimed to tailor a guideline-based computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis., Methods: Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors., Results: The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient., Conclusions: The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time., (©Stijn Van de Velde, Tiina Kortteisto, David Spitaels, Gro Jamtvedt, Pavel Roshanov, Ilkka Kunnamo, Bert Aertgeerts, Per Olav Vandvik, Signe Flottorp. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 11.06.2018.)

Background: Simulation-based training is a widespread strategy to improve health-care quality. However, its effect on registered nurses has previously not been established in systematic reviews. The aim of this systematic review is to evaluate effect of simulation-based training on nurses' skills and knowledge., Methods: We searched CDSR, DARE, HTA, CENTRAL, CINAHL, MEDLINE, Embase, ERIC, and SveMed+ for randomised controlled trials (RCT) evaluating effect of simulation-based training among nurses. Searches were completed in December 2016. Two reviewers independently screened abstracts and full-text, extracted data, and assessed risk of bias. We compared simulation-based training to other learning strategies, high-fidelity simulation to other simulation strategies, and different organisation of simulation training. Data were analysed through meta-analysis and narrative syntheses. GRADE was used to assess the quality of evidence., Results: Fifteen RCTs met the inclusion criteria. For the comparison of simulation-based training to other learning strategies on nurses' skills, six studies in the meta-analysis showed a significant, but small effect in favour of simulation (SMD -1.09, CI -1.72 to -0.47). There was large heterogeneity (I 2 85%). For the other comparisons, there was large between-study variation in results. The quality of evidence for all comparisons was graded as low., Conclusion: The effect of simulation-based training varies substantially between studies. Our meta-analysis showed a significant effect of simulation training compared to other learning strategies, but the quality of evidence was low indicating uncertainty. Other comparisons showed inconsistency in results. Based on our findings simulation training appears to be an effective strategy to improve nurses' skills, but further good-quality RCTs with adequate sample sizes are needed., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the state of quality of care for osteoarthritis (OA) by summarizing studies that have assessed the care provided to patients., Methods: A systematic review of community-based observational studies of actual clinical practice treating people with OA compared with quality indicators (QIs) was performed. Four databases were searched from January 2000 to November 2015. Two reviewers independently determined study eligibility, assessed risk of bias, and extracted study data. The outcome was adherence to the QIs (pass rate). The overall pass rate (the total number of indicators passed divided by the total number of indicators for which the patients were eligible) was extracted from each study. When at least 50% of the studies had comparable individual QIs, the data were pooled with proportion meta-analyses., Results: Fifteen studies comprising 16,103 patients were included, and the median overall pass rate across studies was 41% (range 22-65%). The pooled pass rates for individual QIs were "referral to orthopedic surgeon if no response to other therapy": 59.4% (95% confidence interval [95% CI] 47.5-70.3); "paracetamol or acetaminophen first drug used": 46.0% (95% CI 26.6-66.7); "assessed for pain and/or function": 45.5% (95% CI 33.9-57.6); "referral or recommendation to exercise": 38.7% (28.9-49.5); "offered education and self-management": 35.4% (95% CI 27.8-44.0); and "informed about potential risks if NSAIDs prescribed": 34.1% (95% CI 24.7-44.9)., Conclusion: There is room for improvement in community-based OA care., (© 2016, American College of Rheumatology.)

Background: This paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback., Methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized trials of audit and feedback compared to usual care, with objectively measured outcomes assessing compliance with intended professional practice. Two reviewers independently screened articles and abstracted variables related to the intervention, the context, and trial methodology. The median absolute risk difference in compliance with intended professional practice was determined for each study, and adjusted for baseline performance. The effect size across studies was recalculated as studies were added to the cumulative analysis. Meta-regressions were conducted for studies published up to 2002, 2006, and 2010 in which characteristics of the intervention, the recipients, and trial risk of bias were tested as predictors of effect size., Results: Of the 140 randomized clinical trials (RCTs) included in the Cochrane review, 98 comparisons from 62 studies met the criteria for inclusion. The cumulative analysis indicated that the effect size became stable in 2003 after 51 comparisons from 30 trials. Cumulative meta-regressions suggested new trials are contributing little further information regarding the impact of common effect modifiers. Feedback appears most effective when: delivered by a supervisor or respected colleague; presented frequently; featuring both specific goals and action-plans; aiming to decrease the targeted behavior; baseline performance is lower; and recipients are non-physicians., Discussion: There is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field. There are opportunity costs for patients, providers, and health care systems when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.

Background: The geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes., Methods: A systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination., Results: Five systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach., Conclusions: Overall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.

Background: The geriatric nursing home population is frail and vulnerable to sudden changes in their health condition. Very often, these incidents lead to hospitalization, in which many cases represent an unfavourable discontinuity of care. Analysis of variation in hospitalization rates among nursing homes where similar rates are expected may identify factors associated with unwarranted variation., Objectives: To 1) quantify the overall and diagnosis specific variation in hospitalization rates among nursing homes in a well-defined area over a two-year period, and 2) estimate the associations between the hospitalization rates and characteristics of the nursing homes., Method: The acute hospital admissions from 38 nursing homes to two hospitals were identified through ambulance records and linked to hospital patient journals (n = 2451). Overall variation in hospitalization rates for 2 consecutive years was tested using chi-square and diagnosis-specific variation using Systematic Component of Variation. Associations between rates and nursing home characteristics were tested using multiple regression and ANOVA., Results: Annual hospitalization rates varied significantly between 0.16 and 1.49 per nursing home. Diagnoses at discharge varied significantly between the nursing homes. The annual hospitalization rates correlated significantly with size (r = -0.38) and percentage short-term beds (r = 0.41), explaining 32% of the variation observed (R (2) = 0.319). No association was found for ownership status (r = 0.05) or location of the nursing home (p = 0.52)., Conclusion: A more than nine-fold variation in annual hospitalization rates among the nursing homes in one municipality suggests the presence of unwarranted variation. This finding demands for political action to improve the premises for a more uniform practice in nursing homes.