scholarly journals Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e040025
Author(s):  
SA van Dulmen ◽  
CA Naaktgeboren ◽  
Pauline Heus ◽  
Eva W Verkerk ◽  
J Weenink ◽  
...  
Keyword(s):  
Social Context ◽  
Evidence Synthesis ◽  
Implementation Strategies ◽  
Political Context ◽  
Barriers And Facilitators ◽  
Cochrane Library ◽  
Qualitative Evidence Synthesis ◽  
Organisational Context ◽  
Qualitative Evidence ◽  
Individual Provider

ObjectiveTo assess barriers and facilitators to de-implementation.DesignA qualitative evidence synthesis with a framework analysis.Data sourcesMedline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched.Eligibility criteriaWe included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy.Data extraction and synthesisThe factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context.ResultsWe identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%).ConclusionsThis study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.

scholarly journals The barriers and facilitators to screening in emergency departments: a qualitative evidence synthesis (QES) protocol

2020 ◽  
Vol 3 ◽  
pp. 50
Author(s):  
Louise Barry ◽  
Rose Galvin ◽  
Sylvia Murphy Tighe ◽  
Margaret O'Connor ◽  
Damian Ryan ◽  
...  
Keyword(s):  
Conceptual Model ◽  
Evidence Synthesis ◽  
Grey Literature ◽  
Adverse Outcomes ◽  
Barriers And Facilitators ◽  
Screening Tools ◽  
Cochrane Library ◽  
Qualitative Evidence Synthesis ◽  
Clinical Workflow ◽  
Qualitative Evidence

Background: Early detection of adults at risk of adverse outcomes through systematic screening in the emergency department (ED) can serve to identify high risk groups in need of targeted assessment and early intervention in the hospital or community setting. However, issues such as time pressures, inadequate resources, poor integration of tools into clinical workflow and lack of staff training are cited among the barriers to successfully implementing screening tools in the ED. The aim of this qualitative evidence synthesis (QES) is to synthesize evidence pertaining to the barriers and facilitators to implementing screening tools in the ED. Methods: A comprehensive literature search will be completed in the following databases Scopus, CINAHL, Medline, Embase, Pubmed and Cochrane library. Grey literature sources will also be searched. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of stakeholders on the implementation of screening tools in the ED will be included. “Best fit” framework synthesis will be utilised to produce a context specific conceptual model to describe and explain how these barriers and facilitators may impact on implementation. An a priori framework of themes, formed from the existing evidence base, will inform the ultimate thematic analysis and assist in the organisation and interpretation of search results, ensuring the QES is built upon current findings. CASP will be utilised to quality appraise articles and GRADE CERQual will assess confidence in the QES findings. Conclusions: This synthesis will offer a new conceptual model for describing the perspectives, perceptions and experiences of barriers and facilitators experienced by patients and key stakeholders involved in the implementation of screening tools in the ED. The results of this review will inform practice and aid the development and implementation of change strategies to support the implementation of screening tools in the ED. Registration: PROSPERO CRD42020188712 05/07/20

scholarly journals Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis

2019 ◽  
pp. bmjspcare-2018-001747 ◽  
Author(s):  
Markus Schichtel ◽  
Bee Wee ◽  
John I MacArtney ◽  
Sarah Collins
Keyword(s):  
Heart Failure ◽  
Healthcare Professionals ◽  
Evidence Synthesis ◽  
Barriers And Facilitators ◽  
Cochrane Library ◽  
Emotional Impact ◽  
Qualitative Evidence Synthesis ◽  
Care Plans ◽  
Advance Care ◽  
Disease Specific

BackgroundClinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP.MethodsWe searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators.ResultsOf 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient.ConclusionsTraining healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.

scholarly journals Why do healthcare professionals fail to escalate as per the Early Warning System (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

2021 ◽  
Author(s):  
Sinead M O Neill ◽  
Barbara Clyne ◽  
Miriam Bell ◽  
Avilene Casey ◽  
Brendan Leen ◽  
...  
Keyword(s):  
Early Warning ◽  
Clinical Judgment ◽  
Healthcare Professionals ◽  
Data Extraction ◽  
Evidence Synthesis ◽  
Warning System ◽  
Barriers And Facilitators ◽  
Qualitative Evidence Synthesis ◽  
Quality Appraisal ◽  
Qualitative Evidence

Abstract Background: Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS). Methods: A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorized into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.Results: Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, Empowerement, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation. Conclusions: The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

A qualitative evidence synthesis of users’ experience of mobile health applications in the self-management of type 2 diabetes

2021 ◽  
pp. 174239532098387
Author(s):  
Margaret O’Neill ◽  
Catherine Houghton ◽  
Geraldine Crilly ◽  
Maura Dowling
Keyword(s):  
Type 2 Diabetes ◽  
Health Information ◽  
Mobile Health ◽  
Evidence Synthesis ◽  
Self Management ◽  
Cochrane Library ◽  
Qualitative Evidence Synthesis ◽  
Qualitative Evidence ◽  
Mhealth Apps

Aim The aim of this qualitative evidence synthesis was to identify and synthesise qualitative research relating to experiences of using mobile health (mHealth) applications to aid self-management of Type 2 Diabetes. Methods Using a systematic search strategy, 11 databases were searched (Medline, CINAHL, PsychInfo, PubMed, Web of Science, Embase, Cochrane Library, Scopus, ProQuest A&1, ProQuest UK & Ireland, Mednar). “Best fit” framework synthesis was used guided by the Health Information Technology Acceptance Model (HITAM). Assessment of methodological limitations was conducted using Critical Appraisal Skills Programme (CASP) and confidence in the review findings were guided by GRADE-CERQual. Results Fourteen eligible studies were included in the synthesis (7 qualitative and 5 mixed methods). Key themes identified under the health, information and technology zones of the HITAM revealed the benefits of mHealth apps, barriers to their use, their perceived usefulness and ease of use. Discussion Most people used the apps for feedback on their self-management and found them helpful in their communication with health care providers. Some embraced the technology and found it easy to use while others found mHealth apps to be counterintuitive.

scholarly journals Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
S. M. O’Neill ◽  
B. Clyne ◽  
M. Bell ◽  
A. Casey ◽  
B. Leen ◽  
...  
Keyword(s):  
Early Warning ◽  
Clinical Judgment ◽  
Healthcare Professionals ◽  
Data Extraction ◽  
Evidence Synthesis ◽  
Warning System ◽  
Barriers And Facilitators ◽  
Qualitative Evidence Synthesis ◽  
Quality Appraisal ◽  
Qualitative Evidence

Abstract Background Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS). Methods A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence. Results Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation. Conclusions The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

scholarly journals The barriers and facilitators to implementing screening in emergency departments: a qualitative evidence synthesis (QES) protocol exploring the experiences of healthcare workers

2021 ◽  
Vol 3 ◽  
pp. 50
Author(s):  
Louise Barry ◽  
Rose Galvin ◽  
Sylvia Murphy Tighe ◽  
Margaret O'Connor ◽  
Damian Ryan ◽  
...  
Keyword(s):  
Conceptual Model ◽  
Healthcare Workers ◽  
Evidence Synthesis ◽  
Grey Literature ◽  
Setting Time ◽  
Barriers And Facilitators ◽  
Screening Tools ◽  
Cochrane Library ◽  
Qualitative Evidence Synthesis ◽  
Clinical Workflow

Background: Screening in the emergency department (ED) can identify individuals in need of targeted assessment and early intervention in the hospital or community setting. Time pressures, inadequate resources, poor integration of screening tools into clinical workflow and lack of staff training are barriers to successfully implementing screening in the ED. Tailored implementation processes and education programmes were identified as facilitators. The aim of this QES is to synthesise evidence pertaining to the barriers and facilitators to implementing screening in the ED. This review will focus on the experience of healthcare workers (HCWs) who are involved in this process. Methods: A comprehensive literature search will be completed in Scopus, CINAHL, Medline, Embase, Pubmed and Cochrane library. Grey literature sources will be searched and include Open Grey, Google Scholar, Lenus Irish Health Repository, Science.Gov and Embase Grey Literature. Qualitative or mixed methods studies that include qualitative data on the experiences of HCWs will be included. “Best fit” framework synthesis will be utilised to produce a context specific conceptual model to describe and explain how these barriers and facilitators may impact on implementation. An a priori framework of themes, formed from the existing evidence base, will inform the ultimate thematic analysis and assist in the organisation and interpretation of search results, ensuring the QES is built upon current findings. CASP will be utilised to quality appraise articles and GRADE CERQual will assess confidence in the QES findings. The screening, quality appraisal, data extraction and assessment of confidence in findings will be completed by two reviewers independently and in duplicate. Contingencies for conflict management during these processes will be outlined.   Conclusions: This synthesis, will offer a new conceptual model for describing healthcare workers’ experience of the barriers and facilitators that impact on the implementation of screening tools in the ED.   Registration: PROSPERO CRD42020188712 05/07/20

scholarly journals Exploring the facilitators, barriers, and strategies for self-management in adults living with severe mental illness, with and without long-term conditions: A qualitative evidence synthesis

PLoS ONE ◽  
2021 ◽  
Vol 16 (10) ◽  
pp. e0258937
Author(s):  
Abisola Balogun-Katung ◽  
Claire Carswell ◽  
Jennifer V. E. Brown ◽  
Peter Coventry ◽  
Ramzi Ajjan ◽  
...  
Keyword(s):  
Mental Illness ◽  
Physical Health ◽  
Severe Mental Illness ◽  
Evidence Synthesis ◽  
Barriers And Facilitators ◽  
Self Management ◽  
Qualitative Evidence Synthesis ◽  
Long Term Conditions ◽  
Qualitative Evidence

Background People living with severe mental illness (SMI) have a reduced life expectancy by around 15–20 years, in part due to higher rates of long-term conditions (LTCs) such as diabetes and heart disease. Evidence suggests that people with SMI experience difficulties managing their physical health. Little is known, however, about the barriers, facilitators and strategies for self-management of LTCs for people with SMI. Aim To systematically review and synthesise the qualitative evidence exploring facilitators, barriers and strategies for self-management of physical health in adults with SMI, both with and without long-term conditions. Methods CINAHL, Conference Proceedings Citation Index- Science, HMIC, Medline, NICE Evidence and PsycInfo were searched to identify qualitative studies that explored barriers, facilitators and strategies for self-management in adults with SMI (with or without co-morbid LTCs). Articles were screened independently by two independent reviewers. Eligible studies were purposively sampled for synthesis according to the richness and relevance of data, and thematically synthesised. Results Seventy-four articles met the inclusion criteria for the review; 25 articles, reporting findings from 21 studies, were included in the synthesis. Seven studies focused on co-morbid LTC self-management for people with SMI, with the remaining articles exploring self-management in general. Six analytic themes and 28 sub-themes were identified from the synthesis. The themes included: the burden of SMI; living with co-morbidities; beliefs and attitudes about self-management; support from others for self-management; social and environmental factors; and routine, structure and planning. Conclusions The synthesis identified a range of barriers and facilitators to self-management, including the burden of living with SMI, social support, attitudes towards self-management and access to resources. To adequately support people with SMI with co-morbid LTCs, healthcare professionals need to account for how barriers and facilitators to self-management are influenced by SMI, and meet the unique needs of this population.

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