Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

BackgroundImplementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.Methods and findingsThis multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI −8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI −6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β −9.12 [95% CI −3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β −0.12 [95% CI −0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β −0.19 [−1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI −1.36 to 5.74] p = 0.219; knowledge broker versus control β −0.55 [95% CI −1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β −3.75 [95% CI −8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.ConclusionsOwing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12618000029291.

In a cluster randomized controlled implementation trial, Dr. Mitchell N Sarkies and colleagues examine the effectiveness of knowledge brokering and recommendation dissemination in influencing healthcare resource allocation decisions in Australia and New Zealand.     

Evaluating Written Patient Information for Eczema in German: Comparing the Reliability of Two Instruments,DISCERN and EQIP

Patients actively seek information about how to cope with their health problems, but the quality of the information available varies. A number of instruments have been developed to assess the quality of patient information, primarily though in English. Little is known about the reliability of these instruments when applied to patient information in German. The objective of our study was to investigate and compare the reliability of two validated instruments, DISCERN and EQIP, in order to determine which of these instruments is better suited for a further study pertaining to the quality of information available to German patients with eczema. Two independent raters evaluated a random sample of 20 informational brochures in German. All the brochures addressed eczema as a disorder and/or therapy options and care. Intra-rater and inter-rater reliability were assessed by calculating intra-class correlation coefficients, agreement was tested with weighted kappas, and the correlation of the raters’ scores for each instrument was measured with Pearson’s correlation coefficient. DISCERN demonstrated substantial intra- and inter-rater reliability. It also showed slightly better agreement than EQIP. There was a strong correlation of the raters’ scores for both instruments. The findings of this study support the reliability of both DISCERN and EQIP. However, based on the results of the inter-rater reliability, agreement and correlation analyses, we consider DISCERN to be the more precise tool for our project on patient information concerning the treatment and care of eczema.     

Angiopoietins Modulate Endothelial Adaptation,Glomerular and Podocyte Hypertrophy after Uninephrectomy

Glomerular capillary remodeling is an essential process in the development of glomerular hypertrophy. Angiopoietins, which are important regulators in angiogenesis, plays a role in the development of glomerulus during embryogenesis. Here, we evaluated the influence of angiopoietin on glomerular components and hypertrophy after uninephrectomy in adult male BALB/c mice. The actions of angiopoietin 1 or 2 were systemically antagonized by the subcutaneous administration of antagonists. We observed that the angiopoietin system was activated after uninephrectomy, and that the blockade of angiopoietin 1 or 2 decreased the activation of the angiopoietin receptor—tyrosine kinase with Ig and EGF homology domains-2—and attenuated the development of glomerular and podocyte hypertrophy. The increase in endothelial density staining (anti-CD31) following uninephrectomy was also reversed by angiopoietin 1 or 2 blockades. Glomerular basement thickness and foot process width were observed to decrease in the angiopoietin blockade groups. These changes were associated with the down regulation of the expression of genes for the glomerular matrix and basement membrane, including collagen type IV α1, collagen type IV α2, collagen type IV α5, and laminin α5. Thus, angiopoietin 1 or 2 may play an important role in the development of glomerular hypertrophy after uninephrectomy. A blockade of the angiopoietin system not only influenced the endothelium but also the podocyte, leading to diminished gene expression and morphological changes after uninephrectomy.     

Differences in Leaf Flammability,Leaf Traits and Flammability-Trait Relationships between Native and Exotic Plant Species of Dry Sclerophyll Forest

The flammability of plant leaves influences the spread of fire through vegetation. Exotic plants invading native vegetation may increase the spread of bushfires if their leaves are more flammable than native leaves. We compared fresh-leaf and dry-leaf flammability (time to ignition) between 52 native and 27 exotic plant species inhabiting dry sclerophyll forest. We found that mean time to ignition was significantly faster in dry exotic leaves than in dry native leaves. There was no significant native-exotic difference in mean time to ignition for fresh leaves. The significantly higher fresh-leaf water content that was found in exotics, lost in the conversion from a fresh to dry state, suggests that leaf water provides an important buffering effect that leads to equivalent mean time to ignition in fresh exotic and native leaves. Exotic leaves were also significantly wider, longer and broader in area with significantly higher specific leaf area–but not thicker–than native leaves. We examined scaling relationships between leaf flammability and leaf size (leaf width, length, area, specific leaf area and thickness). While exotics occupied the comparatively larger and more flammable end of the leaf size-flammability spectrum in general, leaf flammability was significantly correlated with all measures of leaf size except leaf thickness in both native and exotic species such that larger leaves were faster to ignite. Our findings for increased flammability linked with larger leaf size in exotics demonstrate that exotic plant species have the potential to increase the spread of bushfires in dry sclerophyll forest.     

Mitochondrial DNA phylogeography of Glyptothorax fokiensis and Glyptothorax hainanensis in Asia

Whole mitochondrial DNA cytochrome b sequences in 62 fish from 13 locations in Southeast China identified two major clades corresponding to two allopatric taxa, Glyptothorax fokiensis fokiensis and Glyptothorax fokiensis hainanensis . Reciprocal monophyly and a molecular clock separation between these two taxa of 2·3 million years indicate these taxa should be elevated to species. Mismatch distributions and Fu's F _S statistic suggest that both G. fokiensis and G. hainanensis have experienced recent population expansions. Analysis of molecular variance indicates that most of the genetic variation resides among populations within both species, with Φ _ST= 0·645 for G. fokiensis and 0·801 for G. hainanensis , suggesting restricted gene flow among populations. Significant correlations between the geographic and the genetic distances provide support for the importance of geographic isolations between populations. Nested clade analysis also confirms low levels of genetic exchanges between the two major groups and between populations within each group. The phylogeographical pattern among populations of Glyptothorax in East Asia can be attributed to historical fragmentations, demographic expansions and occasional long-distance dispersals stimulated by tectonic activity and Ice Age climate changes.