OPTIMISE: a pragmatic stepped wedge cluster randomised trial of an intervention to improve primary care for refugees in Australia

BackgroundLittle is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.MethodsWe conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.ResultsThe intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.ConclusionClinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.Trial registration numberNCT02247050; Pre-results.

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Correction: Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial

PLoS Medicine ◽

10.1371/journal.pmed.1002993 ◽

2019 ◽

Vol 16 (12) ◽

pp. e1002993

Author(s):

Nina Østerås ◽

Tuva Moseng ◽

Leti van Bodegom-Vos ◽

Krysia Dziedzic ◽

Ibrahim Mdala ◽

...

Keyword(s):

Primary Healthcare ◽

Randomised Trial ◽

Cluster Randomised Trial ◽

Stepped Wedge ◽

Structured Model ◽

Cluster Randomised

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Effectiveness of Seasonal Malaria Chemoprevention in Children under Ten Years of Age in Senegal: A Stepped-Wedge Cluster-Randomised Trial

PLoS Medicine ◽

10.1371/journal.pmed.1002175 ◽

2016 ◽

Vol 13 (11) ◽

pp. e1002175 ◽

Cited By ~ 54

Author(s):

Badara Cissé ◽

El Hadj Ba ◽

Cheikh Sokhna ◽

Jean Louis NDiaye ◽

Jules F. Gomis ◽

...

Keyword(s):

Randomised Trial ◽

Cluster Randomised Trial ◽

Stepped Wedge ◽

Cluster Randomised ◽

Seasonal Malaria Chemoprevention

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Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India

BMJ Global Health ◽

10.1136/bmjgh-2018-000907 ◽

2018 ◽

Vol 3 (5) ◽

pp. e000907 ◽

Cited By ~ 3

Author(s):

Ramesh Agarwal ◽

Deepak Chawla ◽

Minakshi Sharma ◽

Shyama Nagaranjan ◽

Suresh K Dalpath ◽

...

Keyword(s):

Quality Of Care ◽

Management Strategy ◽

Randomised Trial ◽

Cluster Randomised Trial ◽

Stepped Wedge ◽

Primary Health ◽

Cluster Randomised ◽

Primary Health Centres ◽

Health Centres

BackgroundLow/middle-income countries need a large-scale improvement in the quality of care (QoC) around the time of childbirth in order to reduce high maternal, fetal and neonatal mortality. However, there is a paucity of scalable models.MethodsWe conducted a stepped-wedge cluster-randomised trial in 15 primary health centres (PHC) of the state of Haryana in India to test the effectiveness of a multipronged quality management strategy comprising capacity building of providers, periodic assessments of the PHCs to identify quality gaps and undertaking improvement activities for closure of the gaps. The 21-month duration of the study was divided into seven periods (steps) of 3 months each. Starting from the second period, a set of randomly selected three PHCs (cluster) crossed over to the intervention arm for rest of the period of the study. The primary outcomes included the number of women approaching the PHCs for childbirth and 12 directly observed essential practices related to the childbirth. Outcomes were adjusted with random effect for cluster (PHC) and fixed effect for ‘months of intervention’.ResultsThe intervention strategy led to increase in the number of women approaching PHCs for childbirth (26 vs 21 women per PHC-month, adjusted incidence rate ratio: 1.22; 95% CI 1.17 to 1.28). Of the 12 practices, 6 improved modestly, 2 remained near universal during both intervention and control periods, 3 did not change and 1 worsened. There was no evidence of change in mortality with a majority of deaths occurring either during referral transport or at the referral facilities.ConclusionA multipronged quality management strategy enhanced utilisation of services and modestly improved key practices around the time of childbirth in PHCs in India.Trial registration numberCTRI/2016/05/006963.

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Impact of patient education on chronic heart failure in primary care (ETIC): a cluster randomised trial

BMC Family Practice ◽

10.1186/s12875-016-0473-4 ◽

2016 ◽

Vol 17 (1) ◽

Cited By ~ 8

Author(s):

Hélène Vaillant-Roussel ◽

Catherine Laporte ◽

Bruno Pereira ◽

Marion De Rosa ◽

Bénédicte Eschalier ◽

...

Keyword(s):

Heart Failure ◽

Primary Care ◽

Chronic Heart Failure ◽

Patient Education ◽

Randomised Trial ◽

Cluster Randomised Trial ◽

Cluster Randomised

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Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records—REDUCE Trial study original protocol

BMJ Open ◽

10.1136/bmjopen-2015-010892 ◽

2016 ◽

Vol 6 (8) ◽

pp. e010892 ◽

Cited By ~ 8

Author(s):

Dorota Juszczyk ◽

Judith Charlton ◽

Lisa McDermott ◽

Jamie Soames ◽

Kirin Sultana ◽

...

Keyword(s):

Primary Care ◽

Electronic Health Records ◽

Respiratory Infections ◽

Randomised Trial ◽

Cluster Randomised Trial ◽

Antibiotic Prescribing ◽

Health Records ◽

Multicomponent Intervention ◽

Cluster Randomised ◽

Electronically Delivered

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Using mHealth tools to improve access, coverage and treatment of uninsured people with high cardiovascular disease risk in Argentina: a study protocol for a pragmatic cluster randomised trial

BMJ Innovations ◽

10.1136/bmjinnov-2017-000255 ◽

2018 ◽

Vol 4 (3) ◽

pp. 135-141 ◽

Cited By ~ 2

Author(s):

Shafika Abrahams-Gessel ◽

Andrea Beratarrechea ◽

Vilma Irazola ◽

Laura Gutierrez ◽

Daniela Moyano ◽

...

Keyword(s):

Cardiovascular Disease ◽

Primary Care ◽

High Risk ◽

Randomised Trial ◽

Text Messages ◽

Cluster Randomised Trial ◽

Cvd Risk ◽

High Risk Patients ◽

Cluster Randomised ◽

Risk Patients

IntroductionCardiovascular disease (CVD) accounts for approximately one-third of Argentina’s deaths. Despite government provision of free primary care health services to the uninsured population, with a focus on non-communicable diseases, screening and management of those with high CVD risk at primary care clinics (PCCs) remain low.Methods and analysisThis pragmatic cluster randomised trial will take place in two provinces of Argentina and will recruit 740 participants. Eight PCCs will be randomised to either the intervention or current practice arm. Community health workers (CHWs) in the intervention arm will be trained to use a set of integrated mHealth tools (a validated risk screening tool mobile application; electronic scheduling system using wireless access to PCCs; and educational text messages) to screen for CVD and to schedule appointments with primary care providers for persons with high CVD risk (≥10%). The primary aims of this study are to determine if the use of mHealth tools will (1) increase attendance of first appointments scheduled by CHWs for persons determined to have high risk for CVD during screening and, (2) lead to an increase in follow-up visits at PCCs by high risk patients. Secondary outcomes include assessing the proportion of high-risk patients receiving appropriate medications and a cost-effective analysis of the intervention.Ethics and disseminationThis study has been approved by the Institutional Review Boards at Partners/Brigham and Women’s Hospital (USA) and the Hospital Italiano de Buenos Aires (Argentina). The open-source software for the mHealth tools will be made publicly available at the end of the study.Trial registration numberNCT02913339.

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