Making shoulder pain simple in general practice: implementing an evidence-based guideline for shoulder pain, protocol for a hybrid design stepped-wedge cluster randomised study (EASIER study)

IntroductionResearch suggests that current care for shoulder pain is not in line with the best available evidence. This project aims to assess the effectiveness, cost-effectiveness and the implementation of an evidence-based guideline for shoulder pain in general practice in Norway.Methods and analysisA stepped-wedge, cluster-randomised trial with a hybrid design assessing clinical effectiveness, cost-effectiveness and the effect of the implementation strategy of a guideline-based intervention in general practice. We will recruit at least 36 general practitioners (GPs) and randomise the time of cross-over from treatment as usual to the implemented intervention. The intervention includes an educational outreach visit to the GPs, a computerised decision tool for GPs and a self-management application for patients. We will measure outcomes at patient and GP levels using self-report questionnaires, focus group interviews and register based data. The primary outcome measure is the patient-reported Shoulder Pain and Disability Index measured at 12 weeks. Secondary outcomes include the EuroQol Quality of Life Measure (EQ5D-5L), direct and indirect costs, patient’s global perceived effect of treatment outcome, Pain Self-Efficacy and Brief Illness Perception Questionnaire. We will evaluate the implementation process with focus on adherence to guideline treatment. We will do a cost–minimisation analysis based on direct and selected indirect costs and a cost–utility analysis based on EQ5D-5L. We will use mixed effect models to analyse primary and secondary outcomes.Ethics and disseminationEthics approval was granted by the Regional Committee for Medical and Health Research Ethics-South East Norway (ref. no: 2019/104). Trial results will be submitted for publication in a peer-reviewed medical journal in accordance with Consolidated Standards of Reporting Trials.Trial registration numberNCT04806191.

Phase-Change Metasurface by U-Shaped Atoms for Photonic Switch with High Contrast Ratio

Currently, diverse metasurfaces act as exotic platforms enabling versatile wave regulations in deep-subwavelength level for ultracompact integration. To address the existing issues of passive nature and low-efficiency in wave controls, one type of metasurface for active phase tuning is proposed in this paper by integrating the phase-change dielectric of Ge2Sb2Te5 into the of U-shaped meta-atoms. Specifically, the phase-change-based hybrid design of Ge2Sb2Te5-integrated metalens switch is demonstrated and numerically confirmed with switchable focusing. The well-defined metal-insulator-metal (MIM) setup is used to enable high-efficiency reflective wavefront tunig and practical Ge2Sb2Te5 phase transition. Upon the phase transition between the amorphous and crystalline states of Ge2Sb2Te5, the cross-polarized component of reflected waves in the given wavelength range is switched “on” (maximized) for as-designed geometric phase plus meta-lensing or “off” (minimized) for no lensing with ultra-high contrast ratio of ~36:1. As a result, such hybrid design of phase-change metasurface may provide a promising route for active photonic device with compact integration.

Making implementation programmes better. Mixed-m​ethods case study of an implementation process for two evidence-based brief psychotherapies

Background The Ostrobothnia Depression Programme (ODP) had a hybrid-design incorporating an implementation programme for two evidence-based treatments (EBTs), behavioural activation and motivational interviewing, and a study on their effectiveness. It was carried out regionally in secondary psychiatric care in a Finnish district. We evaluated the ODP through a mixed-methods analysis to extract organization- and programme-related knowledge to make future programmes more effective in terms of sustaining and scaling up the desired programme outcomes. Methods A cross-sectional mixed-methods survey was conducted with the programme addressees 4-5 months after the end of the ODP. The realization of case consultation groups analysed further by interviewing those responsible for them and making use of attendance lists. Results Out of 72 original programme addressees 33 completed the survey. The results showed that the ODP succeeded in initiating the desired change in clinical practices. Case consultations and training videos intended as reinforcers were underutilized. Deficits in the implementation plan and the hybrid design of the ODP jeopardized the maintenance of the implementation outcomes in the long term. Conclusions We discuss our results in light of the Normalization Process Theory (NPT) related sub-processes ‘implementation’, ‘embedding’ and ‘integration’. The complete training intervention in the target EBTs should comprise both workshops and non-optional case consultations. Access to case consultations should be made as convenient as possible. Means to decentralize the clinical support in everyday work should be elaborated in collaboration with the teams. Coaching team leaders to employ evidence-based active managerial practices that are connected e.g. to the concept of ‘transformational leadership’ would likely be fruitful. The original programme plan should be checked for means to sustain and scale up the implementation outcomes after the active programme phase.