Fidelity of implementation of TB screening guidelines by health providers at selected HIV clinics in Ghana

Introduction Tuberculosis screening of people living with human immunodeficiency virus is an intervention recommended by the WHO to control the dual epidemic of TB and HIV. The extent to which the intervention is adhered to by the HIV healthcare providers (fidelity) determines the intervention’s effectiveness as measured by patient outcomes, but literature on fidelity is scarce. This study assessed provider implementation fidelity to national guidelines on TB screening at HIV clinics in Ghana. Methods It was a cross-sectional study that used structured questionnaires to gather data, involving 226 of 243 HIV healthcare providers in 27 HIV clinics across Ghana. The overall fidelity score comprised sixteen items with a maximum score of 48 grouped into three components of the screening intervention (TB diagnosis, TB awareness and TB symptoms questionnaire). Simple summation of item scores was done to determine fidelity score per provider. In this paper, we define the level of fidelity as low if the scores were below the median score and were otherwise categorized as high. Background factors potentially associated with implementation fidelity level were assessed using cluster-based logistic regression. Odds ratio with 95% confidence interval (CI) was used as the measure of association. Results Of the 226 healthcare providers interviewed, 60% (135) were females with a mean age of 34.5 years (SD = 8.3). Most of them were clinicians [63% (142)] and had post-secondary non-tertiary education [62% (141)]. Overall, 53% (119) of the healthcare providers were categorized to have implemented the intervention with high fidelity. Also, 56% (126), 53% (120), and 59% (134) of the providers implemented the TB diagnosis, TB awareness and TB symptoms questionnaire components respectively with high fidelity. After adjusting for cluster effect, female providers (AOR = 2.36, 95%CI: 1.09–5.10, p = <0.029), those with tertiary education (AOR = 4.31, 95%CI: 2.12–9.10, p = 0.040), and clinicians (AOR = 1.78, 95%CI: 1.07–3.50, p = 0.045) were more likely to adhere to the guidelines compared to their counterparts. Conclusion The number of providers with fidelity scores above the median was marginally greater (6%) than the number with fidelity score below the median. Similarly, for each of the components, the number of providers with fidelity scores higher than the median was marginally higher. This could explain the existing fluctuations in the intervention outcomes in Ghana. We found gender, profession and education were associated with provider implementation fidelity. To improve fidelity level among HIV healthcare providers, and realize the aims of the TB screening intervention among PLHIV in Ghana, further training on implementing all components of the intervention is critical.

AB0140 A HIGH-CONFIDENCE DEFINITION OF THERAPEUTIC RESPONSE IN RHEUMATOID ARTHRITIS USING A MONTE CARLO SIMULATION APPROACH

Background:Therapy choice and therapy change depend on the ability to accurately assess patients’ disease activity. The clinical assessments used to evaluate treatment response in rheumatoid arthritis have inherent variability, normally considered as measurement error, intra-observer variability or within subject variability. Each contribute to variability in deriving response status as defined by composite measures such as the ACR or EULAR criteria, particularly when a one-time observed measurement lies near the boundary defining response or non-response. To select an optimal therapeutic strategy in the burgeoning age of precision medicine in rheumatology, achieve the lowest disease activity and maximize long-term health outcomes for each patient, improved treatment response definitions are needed.Objectives:Develop a high-confidence definition of treatment response and non-response in rheumatoid arthritis that exceeds the expected variability of subcomponents in the composite response criteria.Methods:A Monte Carlo simulation approach was used to assess ACR50 and EULAR response outcomes in 100 rheumatoid arthritis patients who had been treated for 6 months with a TNF inhibitor therapy. Monte Carlo simulations were run with 2000 iterations implemented with measurement variability derived for each clinical assessment: tender joint count, swollen joint count, Health Assessment Questionnaire disability index (HAQ-DI), patient pain assessment, patient global assessment, physician global assessment, serum C-reactive protein level (CRP) and disease activity score 28-joint count with CRP.1-3 Each iteration of the Monte Carlo simulation generated one outcome with a value of 0 or 1 indicating non-responder or responder, respectively.Results:A fidelity score, calculated separately for ACR50 and EULAR response, was defined as an aggregated score from 2000 iterations reported as a fraction that ranges from 0 to 1. The fidelity score depicted a spectrum of response covering strong non-responders, inconclusive statuses and strong responders. A fidelity score around 0.5 typified a response status with extreme variability and inconclusive clinical response to treatment. High-fidelity scores were defined as >0.7 or <0.3 for responders and non-responders, respectively, meaning that the simulated clinical response status label among all simulations agreed at least 70% of the time. High-confidence true responders were considered as those patients with high-fidelity outcomes in both ACR50 and EULAR outcomes.Conclusion:A definition of response to treatment should exceed the expected variability of the clinical assessments used in the composite measure of therapeutic response. By defining high-confidence responders and non-responders, the true impact of therapeutic efficacy can be determined, thus forging a path to development of better treatment options and advanced precision medicine tools in rheumatoid arthritis.References:[1]Cheung, P. P., Gossec, L., Mak, A. & March, L. Reliability of joint count assessment in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum43, 721-729, doi:10.1016/j.semarthrit.2013.11.003 (2014).[2]Uhlig, T., Kvien, T. K. & Pincus, T. Test-retest reliability of disease activity core set measures and indices in rheumatoid arthritis. Ann Rheum Dis68, 972-975, doi:10.1136/ard.2008.097345 (2009).[3]Maska, L., Anderson, J. & Michaud, K. Measures of functional status and quality of life in rheumatoid arthritis: Health Assessment Questionnaire Disability Index (HAQ), Modified Health Assessment Questionnaire (MHAQ), Multidimensional Health Assessment Questionnaire (MDHAQ), Health Assessment Questionnaire II (HAQ-II), Improved Health Assessment Questionnaire (Improved HAQ), and Rheumatoid Arthritis Quality of Life (RAQoL). Arthritis Care Res (Hoboken) 63 Suppl 11, S4-13, doi:10.1002/acr.20620 (2011).Disclosure of Interests:Vibeke Strand Consultant of: Abbvie, Amgen, Arena, BMS, Boehringer Ingelheim, Celltrion, Galapagos, Genentech/Roche, Gilead, GSK, Ichnos, Inmedix, Janssen, Kiniksa, Lilly, Merck, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Setpoint, UCB, Stanley Cohen: None declared, Lixia Zhang Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Ted Mellors Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Alex Jones Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Johanna Withers Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Viatcheslav Akmaev Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation

Authentication of the P2P Network using the Aggregated Fidelity Score Method

The most important issue in the P2P network is authenticating whether a network can be fully trusted before permitting full access and if the non-credible peers in a network gains access to the network it will actually cause lot of security related problems like man in the middle attack and denial of access attack. To overcome these attacks and to safe guard the peer network, a new fidelity based method is presented in this paper. The notion here is to calculate the loyalty score of the network based on the percentage of data delivered successfully and search time taken by the node and then if the score is higher than the permissible threshold value, the network is considered as a credible network and if the score is less, then the data on the network is blocked to ensure the curtail of the aforementioned attacks. The simulation results showcased that the proposed fidelity based approach is superior and performed with a high success rate and with less delay and drop rates.

‘Another tool in my toolbox’: Training school teaching assistants to use dynamic temporal and tactile cueing with children with childhood apraxia of speech

This study explored the feasibility of training school teaching assistants to provide the treatment, Dynamic Temporal and Tactile Cueing to treat childhood apraxia of speech (CAS, also known as developmental verbal dyspraxia). The study used a single case experimental design across behaviours and a qualitative evaluation of teaching assistant experiences using interviews. Two student-teaching assistant dyads participated. One child was aged 6;2 (6 years 2 months) and the other 5;6 at the time of the study. Both participants had speech characteristics consistent with the features outlined in the 2007 Technical Report on CAS from the American Speech and Language Hearing Association (ASHA). These included lengthened and disrupted coarticulatory transitions between sounds and syllables, inappropriate prosody and inconsistent errors on consonants and vowels. Treatment outcomes were measured using visual analysis and calculations of total-change improvement rate difference (TC-IRD) and composite IRD (C-IRD) based on percent of phonemes correct. Fidelity to the treatment protocol was measured using a Fidelity Score. Visual analysis of both child participant’s data showed an upward trend for all treatment and similar words and a flatter trajectory for control words. Both child participants had a TC-IRD score of 100% for all treatment words. One child also had a TC-IRD score of 100% for their similar words and a TC-score of 25% for their control words. The second child had a TC-score of 67% for similar and control words. Both teaching assistants had a Fidelity Score of over 90%. Both teaching assistants reported positive experiences in conducting the program. Training teaching assistants may be an effective means of providing treatment to children with CAS while they are at school. Training teaching assistants also helps to improve their capacity which may have positive implications in their interactions with other children with speech sound disorders.

C-FIT adolescent diversion program: A behavioral intervention pilot test for delinquent offenders

The Community-Family Integration Teams (C-FIT) diversion program was developed to address behavioral and mental health treatment for justice-involved adolescents. The C-FIT pilot study, implemented in Jordan, aimed to (1) evaluate intervention fidelity and (2) assess intervention effectiveness. Adolescent males ( n = 19) and their families participated in the C-FIT study. Pre and post data were collected through interviews and standardized instruments. The mean fidelity score was 31.4 out of 46 (68%), indicating reasonable fidelity. Data suggest declining levels of internalizing problems. The C-FIT program holds promise for improving adolescent mental health outcomes and decreasing recidivism youths who are at risk of detention center placement.

Predictive validity of evidence-based practices in supported employment: a systematic review and meta-analysis

Purpose The purpose of this paper is to explore the predictive validity of two measures of fidelity to the individual placement and support (IPS) approach to supported employment. Design/methodology/approach A systematic review and meta-analysis was conducted of IPS programs. In total, 30 studies provided information characterizing 69 cohorts and 8,392 participants. Predictive validity was assessed by a precision and negative prediction analysis and by multivariate analysis of deviance. Findings Fidelity scores on the IPS-15 scale of 60 or less accurately predicted poor outcomes, defined as 43 percent or less of participants commencing employment, in 100 percent of cohorts. Among cohorts with IPS-15 fidelity scores of 61-75, 63 percent attained good employment outcomes defined as 44 percent or more commencing employment. A similar pattern emerged from the precision analysis of the smaller sample of IPS-25 cohorts. Multivariate analysis of deviance for studies using the IPS-15 scale examined six cohort characteristics. Following adjustment for fidelity score, only fidelity score (χ2=15.31, df=1, p<0.001) and author group (χ2=35.01, df=17, p=0.01) representing an aspect of cohort heterogeneity, remained associated with commencing employment. Research limitations/implications This study provides evidence of moderate, yet important, predictive validity of the IPS-15 scale across diverse international and research contexts. The smaller sample of IPS-25 studies limited the analysis that could be conducted. Practical implications Program implementation leaders are encouraged to first focus on attaining good fidelity, then supplement fidelity monitoring with tracking the percentage of new clients who obtain a competitive job employment over a pre-defined period of time. Originality/value The evidence indicates that good fidelity may be necessary but not sufficient for good competitive employment outcomes.