Care for capabilities: Implementing the capability approach in rehabilitation of patients with neuromuscular diseases. Study protocol of the controlled before-after ReCap-NMD study

Background High quality care of patients with neuromuscular diseases requires a personalised approach that focuses on achieving and maintaining a level of functioning that enables them to be in a state of well-being. The capability approach states that well-being should be understood in terms of capabilities, the substantial opportunities that people have to be and do things they have reasons to value. In this Rehabilitation and Capability care for patients with Neuromuscular diseases (ReCap-NMD) study, we want to investigate whether providing care based on the capability approach (capability care) has an added value in the rehabilitation of patients with neuromuscular diseases (NMD). Methods Two groups of 30 adult patients with facioscapulohumeral muscular dystrophy or myotonic dystrophy type 1 will be included. The first group will receive rehabilitation care as usual with a follow-up period of 6 months. Then, based on theory, and experiences of patients and healthcare professionals, capability care will be developed. During the following 3 months, the multidisciplinary outpatient rehabilitation care team will be trained in providing this newly developed capability care. Subsequently, the second group will receive capability care, with a follow-up period of 6 months. A mixed methods approach is used with both qualitative and quantitative outcome measures to evaluate the effect of capability care and to perform a process evaluation. The primary outcome measure will be the Canadian Occupational Performance Measure. Discussion The ReCap-NMD study is the first study to design and implement a healthcare intervention based on the capability approach. The results of this study will expand our knowledge on how the capability approach can be applied in delivering and evaluating healthcare, and will show whether implementing such an intervention leads to a higher well-being for patients with NMD. Trial registration Registered at Trialregister.nl (Trial NL8946) on 12th of October, 2020.

Bibliometric study of ‘overviews of systematic reviews’ of health interventions: evaluation of prevalence, citation and impact factor

Background: Overviews synthesising the results of multiple systematic reviews help inform evidence-based clinical practice. In this first of two companion papers, we evaluate the bibliometrics of overviews, including their prevalence and factors affecting citation rates and JIF (JIF).Methods: We searched MEDLINE, Epistemonikos and Cochrane Database of Systematic Reviews (CDSR). We included overviews that: (a) synthesised reviews, (b) conducted a systematic search, (c) had a methods section, and (d) examined a healthcare intervention. Multivariable regression was conducted to determine the association between citation density, JIF and 6 predictor variables. Results: We found 1218 overviews published from 2000 to 2020; the majority (73%) were published in the most recent 5-year period. We extracted a selection of these overviews (n=541; 44%) dated from 2000 to 2018. The 541 overviews were published in 307 journals; CDSR (8%), PLOS ONE (3%) and Sao Paulo Medical Journal (2%) were the most prevalent. The majority (70%) were published in journals with impact factors between 0.05 and 3.97. We found a mean citation count of 10 overviews per year, published in journals with a mean JIF of 4.4. In multivariable analysis, overviews with a high number of citations and JIFs had more authors, larger sample sizes, were open access and reported the funding source. Conclusions: An 8-fold increase in the number of overviews was found between 2009 and 2020. We identified 332 overviews published in 2020, which is equivalent to 1 overview published per day. Overviews perform above average for the journals in which they publish.

A mobile cesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol

Background As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. Methods We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. Discussion Completion of our study aims will allow us to describe participants’ perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. Trial registration There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

An Integrated Medical-Psychological Approach in the Routine Care of Patients with Type 2 Diabetes: A Pilot Study to Explore the Clinical and Economic Sustainability of the Healthcare Intervention

The economic burden of Type 2 Diabetes Mellitus (T2DM) is a challenge for sustainability. Psychological factors, healthy behaviors, and stressful conditions are predictive and prognostic factors for T2DM. Focusing on psychological factors can reduce costs and help ensure the sustainability of diabetes care. The study aimed to support an integrated medical-psychological approach in the care of patients with T2DM. A group of patients undergoing usual healthcare treatment was compared to patients who received a psychotherapeutic intervention in addition to standard treatment. The study’s outcomes were: physical health (blood glucose, glycated hemoglobin, blood lipids, blood pressure); lifestyle (cigarettes, alcoholic drinks, physical activity, body mass index); mental health (anxiety, depression, stress, coping styles, alexithymia, emotion regulation, locus of control); costs (number of referrals to a specialist, standard cost of each visit). We examined the change from baseline to 24-week follow-up. Compared to the Standard Group, the Integrated Group reported a reduction in blood lipids and triglycerides, chronic depressive and anxious mood states, patient emotional coping, and the number of specialist visits and diagnostic tests. Close collaboration between diabetologists and psychologists is feasible, and it is worth considering integrated care as an option to contain and make healthcare spending more sustainable.

The Cost Effectiveness of Ecotherapy as a Healthcare Intervention, Separating the Wood from the Trees

Internationally, shifts to more urbanised populations, and resultant reductions in engagements with nature, have been a contributing factor to the mental health crisis facing many developed and developing countries. While the COVID-19 pandemic reinforced recent trends in many countries to give access to green spaces more weight in political decision making, nature-based activities as a form of intervention for those with mental health problems constitute a very small part of patient pathways of care. Nature-based interventions, such as ecotherapy, are increasingly used as therapeutic solutions for people with common mental health problems. However, there is little data about the potential costs and benefits of ecotherapy, making it difficult to offer robust assessments of its cost-effectiveness. This paper explores the capacity for ecotherapy to be cost-effective as a healthcare intervention. Using a pragmatic scoping review of the literature to understand where the potential costs and health benefit lie, we applied value of information methodology to identify what research is needed to inform future cost-effectiveness assessments. We show that there is the potential for ecotherapy for people with mild to moderate common mental health problems to be cost-effective but significant further research is required. Furthermore, nature-based interventions such as ecotherapy also confer potential social and wider returns on investment, strengthening the case for further research to better inform robust commissioning.

Information systems in support of public health in high-income countries

Public health activities are dependent on the availability of information and ability to disseminate information to clinicians/healthcare providers, individuals, and communities. The increasing computerization of healthcare systems can offer opportunities to improve these activities. Databases of electronic healthcare records are used for disease surveillance and monitoring healthcare interventions. The quality and quantity of reporting of notifiable diseases may be improved by regular review of the electronic healthcare records. Randomized trials that recruit patients at the point of care and use electronic healthcare records for collection of follow-up information can be used to test the effectiveness of healthcare intervention in routine clinical practice. Cluster trials that randomize different clinics or regions can compare different public health policies and improve the evidence base for the pragmatic use of public health interventions. Data generated within clinical information systems can be used to provide feedback and guidance to clinicians and patients as part of clinical care. Better information systems providing data on risks and benefits of healthcare interventions will provide an important impetus to evidence-based public health.

145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach

Background Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another. Methods We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016. Results We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096). Conclusion The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development. Disclosures Matthew B. Goetz, MD, Nothing to disclose

A Nested Qualitative Evaluation of User Experiences in a Randomized Trial of a Digital Intervention To Support Total-Skin-Self-Examination By Melanoma Survivors

BackgroundMelanoma is a common cancer with a high survival rate, as well as a high chance of recurrence. Combined, this leads to a high burden of follow-up. Total-Skin-Self-Examination (TSSE) improves clinical outcomes of melanoma via early detection of new primaries and recurrences, and technology is an increasingly popular means of facilitating TSSE. Thus, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) digital healthcare intervention was developed. Embedded within a randomised control trial (RCT), this nested study used qualitative interviews to explore in depth participants’ experiences of TSSE, their orientation toward technology and both participant and professionals’ practical and technical experiences of the ASICA intervention.MethodsSemi-structured telephone interviews were undertaken during the RCT with participants and the coordinating Dermatology Nurse Practitioner (DNP). Participants were purposively sampled to achieve a representative sample. Interviews were transcribed verbatim and analysed using a Framework Analysis approach applied within NVivo12.ResultsTwenty-two interviews were completed with participants and one with the coordinating DNP. ASICA appeared to change participants’ perceptions of skin checking: users were more likely to report routinely performing TSSE thoroughly. There was some variation in beliefs about skin-checking and using technology for healthcare generally. Overall, ASICA was experienced positively by participants and the DNP. Several clear practical suggestions were made for how ASICA can be improved.ConclusionThe ASICA app appears to have positively influenced the attitudes and TSSE practices of melanoma survivors. Technical improvements are required, but the app offers promise for technologically enhanced melanoma follow-up in future.Trial RegistrationClinical Trials.gov, NCT03328247. Registered on 1 November 2017 - https://clinicaltrials.gov/ct2/show/NCT03328247?term=ASICA&rank=1

Overuse and underuse of cardiovascular diagnostic and therapeutic procedures for community-dwelling adults: a protocol for a systematic review

Background: Potentially inappropriate care can result from overuse or underuse of treatments, tests, or procedures. Overuse is defined as the use of health services with no clear benefit to the recipient or where harms outweigh benefits and/or costs of care. Underuse is defined as failure to deliver an effective and cost-effective healthcare intervention. Cardiovascular procedures such as coronary artery bypass grafting, carotid endarterectomy, coronary angiography, and coronary angioplasty (with/without stenting) are potentially both underused and overused. This systematic review aims to identify rates of potential overuse and underuse of these cardiovascular procedures and explore any associated patient or healthcare system factors. Methods: A systematic review and meta-analysis will be conducted in accordance with the PRISMA guidelines. A systematic search of MEDLINE (via Ovid), Embase, Cumulative Index to Nursing and Allied Health Literature and the Cochrane library will be conducted using a predefined search strategy. Eligible studies for inclusion will examine rates of overuse and underuse of cardiovascular procedures, measured against national/international guidelines, for adults aged ≥18 years. Primary observational studies including cross-sectional and cohort studies will be included. Titles, abstracts, and full texts will be screened for inclusion by two reviewers. Data will be extracted using a standardised form. Risk of bias for all included studies will be assessed using a modified version of the Hoy risk of bias tool. Where adequate data exists, and if statistically appropriate, meta-analyses will be conducted. If statistical pooling of the data is not possible, the findings will be narratively summarised focusing on the review’s objectives. Conclusion: This systematic review will examine overuse and underuse of cardiovascular procedures for adults. The results will help inform policy makers, researchers, patients, and clinicians in the appropriate use of these procedures, in line with international guidelines. Registration: This protocol has been submitted for registration on PROSPERO (CRD42021239041).

Development of a web-based, guided self-help, ACT-based intervention for weight loss maintenance: an evidence-, theory- and person-based approach. (Preprint)

BACKGROUND The long-term impact and cost-effectiveness of weight management programmes depends on post-treatment weight maintenance. There is growing evidence that interventions based on third-wave cognitive behavioural therapy (3wCBT), specifically acceptance and commitment therapy (ACT), could improve long-term weight management however these interventions are typically delivered face-to-face by psychologists, which limits the scalability of this type of intervention. OBJECTIVE To use an evidence-, theory- and person-based approach to develop an ACT-based intervention for weight-loss maintenance that uses digital technology and non-specialist guidance to minimise resources needed for delivery at scale. METHODS Intervention development was guided by the Medical Research Council framework for the development of complex interventions in healthcare, Intervention Mapping Protocol, and the person-based approach for enhancing the acceptability and feasibility of interventions. Two phases of work were conducted: phase one consisted of collating and analysing existing and new primary evidence, and phase two consisted of theoretical modelling and intervention development. Phase one included a synthesis of existing evidence on weight-loss maintenance from previous research, a systematic review and network meta-analysis of 3wCBT interventions for weight management, a qualitative interview study of experiences of weight-loss maintenance, and the modelling of a justifiable cost for a weight-loss maintenance programme. Phase two included iterative development of guiding principles, a logic model and the intervention design and content. Target user and stakeholder panels were established to inform each phase of development and user-testing of successive iterations of the prototype intervention were conducted. RESULTS This process resulted in a guided self-help ACT-based intervention called SWiM (Supporting Weight Management). SWiM is a 4-month programme, consisting of weekly web-based sessions for 13 consecutive weeks, followed by a 4-week break for participants to reflect and practice their new skills, and a final session at week 17. Each session consists of psychoeducational content, reflective exercises, and behavioural experiments. SWiM includes specific sessions on key determinants of weight-loss maintenance, including developing skills to manage high-risk situations for lapses, creating new helpful habits, breaking old unhelpful habits, and learning to manage interpersonal relationships and their impact on weight-management. A trained, non-specialist coach provides guidance for participants through the programme with four scheduled 30-minute telephone calls and three further optional calls. CONCLUSIONS This comprehensive approach facilitated the development of an intervention that is based on scientific theory and evidence of how to support people with weight-loss maintenance, and is grounded in the experiences of the target users and the context in which it is intended to be delivered. The intervention will be refined based on findings of a planned pilot randomised controlled trial.