Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series

Background

The recent development and publication of evidence-based clinical practice guidelines (CPGs) for acute low back pain (LBP) has resulted in evidence-based recommendations that, if implemented, have the potential to improve the quality and safety of care for acute LBP. While a strategy has been specified for dissemination of the CPG for acute LBP in Australia, there is no accompanying plan for active implementation. Evidence regarding the cost-effectiveness of active implementation of CPGs for acute LBP is sparse. The IMPLEMENT study will consider the incremental benefits and costs of progressing beyond development and dissemination to implementation.

Methods/design

Cost-effectiveness and cost-utility analyses alongside the IMPLEMENT cluster randomised controlled trial (CRCT) from a societal perspective to quantify the additional costs (savings) and health gains associated with a targeted implementation strategy as compared with access to the CPG via dissemination only.

Discussion

The protocol provided here registers our intent to conduct an economic evaluation alongside the IMPLEMENT study, facilitates peer-review of proposed methods and provides a transparent statement of planned analyses.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN012606000098538     

Synchronization and stochastic resonance of the small-world neural network based on the CPG

According to biological knowledge, the central nervous system controls the central pattern generator (CPG) to drive the locomotion. The brain is a complex system consisting of different functions and different interconnections. The topological properties of the brain display features of small-world network. The synchronization and stochastic resonance have important roles in neural information transmission and processing. In order to study the synchronization and stochastic resonance of the brain based on the CPG, we establish the model which shows the relationship between the small-world neural network (SWNN) and the CPG. We analyze the synchronization of the SWNN when the amplitude and frequency of the CPG are changed and the effects on the CPG when the SWNN’s parameters are changed. And we also study the stochastic resonance on the SWNN. The main findings include: (1) When the CPG is added into the SWNN, there exists parameters space of the CPG and the SWNN, which can make the synchronization of the SWNN optimum. (2) There exists an optimal noise level at which the resonance factor Q gets its peak value. And the correlation between the pacemaker frequency and the dynamical response of the network is resonantly dependent on the noise intensity. The results could have important implications for biological processes which are about interaction between the neural network and the CPG.     

Evaluation of clinical practice guidelines.

Compared with the current focus on the development of clinical practice guidelines the effort devoted to their evaluation is meagre. Yet the ultimate success of guidelines depends on routine evaluation. Three types of evaluation are identified: evaluation of guidelines under development and before dissemination and implementation, evaluation of health care programs in which guidelines play a central role, and scientific evaluation, through studies that provide the scientific knowledge base for further evolution of guidelines. Identification of evaluation and program goals, evaluation design and a framework for evaluation planning are discussed.     

Translating guidelines into practice: a systematic review of theoretic concepts,practical experience and research evidence in the adoption of clinical practice guidelines

OBJECTIVE: To recommend effective strategies for implementing clinical practice guidelines (CPGs). DATA SOURCES: The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE from January 1990 to June 1996, inclusive, with the use of the MeSH heading "practice guidelines" and relevant text words. STUDY SELECTION: Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians'' performance or health care outcomes were emphasized. DATA EXTRACTION: Articles were reviewed to determine the effect of various factors on the adoption of guidelines. DATA SYNTHESIS: The articles showed that CPG dissemination or implementation processes have mixed results. Variables that affect the adoption of guidelines include qualities of the guidelines, characteristics of the health care professional, characteristics of the practice setting, incentives, regulation and patient factors. Specific strategies fell into 2 categories: primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines. The interventions were shown to be weak (didactic, traditional continuing medical education and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers and delivered by peers or opinion leaders) and relatively strong (reminder systems, academic detailing and multiple interventions). CONCLUSIONS: The evidence shows serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic.     

A meeting center for people from Surinam with dementia and their informal caregivers. Development and implementation of culture specific combined support

In this study we investigated the implementation of a support programme for Surinam people with dementia and their carers. The reason for setting up a new type of support was the finding that the regular care is unable to meet the needs of elderly people from ethnic minorities and their carers. We traced facilitating and impeding factors in the successful implementation of the support programme. We also evaluated the result of the implementation. Data were gathered among participants in the programme (n=24) by means of questionnaires. Semi-structured interviews were conducted with key figures (n=8) involved in setting up and implementing the meeting centre. The interview data were double coded and analyzed, using the computer programme NVivo. Demonstrably favourable factors for setting up the support program were: a thorough preliminary study and a type of support that is in line with the views of the organizations involved. Several factors proved to play a facilitating role during the phases of preparation and implementation, for example: motivated initiators and staff, effective cooperation between organizations and adequate financial resources. With regard to the result of the implementation, we concluded that this culture-specific type of support is feasible and successful; the targeted population is reached, people with dementia and their carers are satisfied with the support, and the attendance at the different elements of the support program has been very satisfactory.     

NDRG2 and TLR7 as novel DNA methylation prognostic signatures for acute myelocytic leukemia

Acute myelocytic leukemia (AML) is an aggressive malignant tumor and typically fatal without treatment. Identification and development of novel biomarkers could be beneficial for the diagnosis and prognosis of AML patients. Here, we aimed to identify the accurate DNA methylation prognostic signatures for AML patients. The DNA methylation data of AML patients and corresponding clinical information were retrieved from The Cancer Genome Atlas database. CPG sites that correlates closely with the survival of the AML patients were identified and further combined into CPG sites pairs to screen the survival-related pairs. The prognostic signatures were identified by the C-index and forward search algorithms and validated by the verification group. Finally, the functional enrichment analysis was performed on these CPG sites. As a result, a total of 498 CPG sites associated with the overall survival of AML patients was obtained. A prognostic signature composed of 10 CPG sites pairs was obtained and validated. The functional enrichment analysis showed prognostic genes were mainly enriched in tumor protein processing, cell differentiation, blood leukocyte immunity, and platelet growth factor pathways. In summary, we identified two accurate prognostic methylation signatures (NDRG2 and TLR7), which would be served as a novel therapy target for AML.     

Conflict of Interest Disclosures for Clinical Practice Guidelines in the National Guideline Clearinghouse

Background

Conflict of interest (COI) is an important potential source of bias in the development of clinical practice guidelines (CPGs) and high rates of COI among guideline authors have been reported in the past. Our objective was to report current rates of disclosure and specific author COI across a broad range of CPGs and to examine whether CPG characteristics were associated with the presence of disclosures and of conflicts.

Methods and Findings

We selected a random sample of 250 CPGs listed in the National Guideline Clearinghouse on November 22, 2010, representing approximately a 10% sample of guidelines listed in the NGC on that date. We abstracted information on author COI from each CPG and examined predictors of the disclosures and COI using a logistic generalized estimating equation regression model. 87% of organizations developing guidelines had a CPG-specific policy, however, 40% of CPGs did not indicate that they had collected disclosures from guideline authors. In addition, 42% of organizations that did collect author disclosures did not have those disclosures available in the public domain. Of CPGs where we had disclosures for all authors, 60% had one or more authors with a conflict. On average, 28% of the authors of CPGs with available disclosures had a COI. Guidelines that were published in journals with an impact factor greater than 5.0 were more likely to have one or more authors with a COI than guidelines not published in journals.

Conclusions

Rates of disclosure of author COI and the public availability of that information are unacceptably low, however rates of COI among guideline authors may have decreased in recent years. Continued efforts are needed to establish and enforce optimal COI policies in clinical practice guideline development in order to minimize the risk of bias associated with those conflicts.     

Healthcare Professionals’ and Policy Makers’ Views on Implementing a Clinical Practice Guideline of Hypertension Management: A Qualitative Study

IntroductionMost studies have reported barriers to guideline usage mainly from doctors’ perspective; few have reported the perspective of other stakeholders. This study aimed to determine the views and barriers to adherence of a national clinical practice guideline (CPG) on management of hypertension from the perspectives of policymakers, doctors and allied healthcare professionals.MethodsThis study used a qualitative approach with purposive sampling. Seven in depth interviews and six focus group discussions were conducted with 35 healthcare professionals (policy makers, doctors, pharmacists and nurses) at a teaching hospital in Kuala Lumpur, Malaysia, between February and June 2013. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyse the data.ResultsTwo main themes and three sub-themes emerged from this study. The main themes were (1) variation in the use of CPG and (2) barriers to adherence to CPG. The three sub-themes for barriers were issues inherent to the CPG, systems and policy that is not supportive of CPG use, and attitudes and behaviour of stakeholders. The main users of the CPG were the primary care doctors. Pharmacists only partially use the guidelines, while nurses and policy makers were not using the CPG at all. Participants had suggested few strategies to improve usage and adherence to CPG. First, update the CPG regularly and keep its content simple with specific sections for allied health workers. Second, use technology to facilitate CPG accessibility and provide protected time for implementation of CPG recommendations. Third, incorporate local CPG in professional training, link CPG adherence to key performance indicators and provide incentives for its use.ConclusionsBarriers to the use of CPG hypertension management span across all stakeholders. The development and implementation of CPG focused mainly on doctors with lack of involvement of other healthcare stakeholders. Guidelines should be made simple, current, reliable, accessible, inclusive of all stakeholders and with good policy support.     

Implementing Evidence-Based Programs: Lessons Learned From the Field

Evidence-based programs (EBPs) are used in many health promotion efforts to ensure that the intended positive behavioral and health outcomes will be achieved. However, because EBPs are developed and tested in research settings, the contextual elements of real world implementation play an important role in their successful delivery in communities. As an intermediary charged with supporting the translation of research to practice for a statewide teen pregnancy prevention initiative, the ACT for Youth Center of Excellence conducted a mid-course evaluation to identify factors that contribute to the successful implementation of EBPs. The findings indicate that successful implementation involves systematic planning that addresses three critical contextual factors: community readiness, organizational capacity, and setting characteristics. By attending both to factors identified from local practice, and to theory and evidence identified through implementation science, practitioners can strengthen programming and enhance the quality of EBP delivery.     

A large-scale transcriptome analysis identified ELANE and PRTN3 as novel methylation prognostic signatures for clear cell renal cell carcinoma

DNA methylation was involved in the progress of many types of cancer including clear cell renal cell carcinomas (ccRCCs). This study aimed to identify the prognostic DNA methylation biomarkers for the ccRCCs by a large-scale RNA-seq analysis. The DNA methylation data and the corresponding clinical information of the patients with ccRCCs were extracted from TCGA database and randomly divided into the training group and the validation group. The differentially expressed CpG sites and the survival-related CpG sites were further identified, which was combined into CpG sites pair and followed by screening the survival-related pairs. The C-index and the forward search algorithms were constructed to identify the prognostic signatures for the patients with ccRCCs. The prognostic signatures were verified by the validation dataset and the protein–protein interactions (PPI) network analysis was performed on the CPG sites of the signature. A total of 9,861 differentially expressed CPG sites were identified and 567 CpG sites were found to relate to the overall survival (OS) of the patients with ccRCCs. Besides, 1,146 CPG sites pairs were found to be related to the OS of the ccRCCs samples and the signature composed of seven CpG sites pairs were obtained to predict the prognosis of patients with ccRCCs and the results were verified in the validation dataset. Besides, the PPI network analysis showed that ELANE and PRTN3 gene may be associated with the invasion and metastasis of ccRCCs and could function as potential prognostic and therapeutic signatures for ccRCCs.     

Effects on hypothalamus when CPG is fed back to basal ganglia based on KIV model

The KIV model approximates the operation of the basic vertebrate forebrain together with the basal ganglia and motor systems. In KIV model, the hypothalamus and the basal ganglia which are two important parts in the midline forebrain are closely associated with the locomotion. The CPG model with time delay is established in this paper and the stability of this CPG model is discussed. The CPG output is treated as the proprioception and fed back to the basal ganglia. We focus on the effects on the hypothalamus and the basal ganglia when the time delay parameter a_d, the CPG amplitude parameter e and the CPG frequency parameter T_r are changed. Through analysis, we find that there exists optimum value of the parameters a_d or T_r which can make the synchronization of the hypothalamus optimum when the CPG is added into the basal ganglia. The results could have important implications for biological processes which are about interaction between the neural network and the CPG.     

Influences on biology teachers' reported familiarity with and use of new curriculum materials

A survey of science teachers in 17 Local Education Authorities reveals wide dissemination and high adoption of materials from Nuffleld O-level and A-level biology schemes. Teachers identified as high adopters, in contrast to low adopters, rated 4 factors as facilitating use of the materials ; time available for preparation, availability of special grants to start projects, availability of money to keep projects going, requirements of external examinations.

High adopters were also more frequent users of seven sources of information; specialist subject journals, science journals and magazines, catalogues from scientific supply companies, university staff, and meetings in professional centres, universities and other higher or further education institutions.

High adopters also viewed, as important outcomes of science teaching, the development of favourable attitudes and, as not important, the ability to take personal responsibility for pupil planning of learning experiences and the development of pupils' ability to work together as a group.

High adopters agreed more strongly with 3 effects of projects; they provide idealists with a platform, increase outside support for change and do not influence the internal organisation of schools.     

Awareness and Attitude towards Human Papillomavirus (HPV) Vaccine among Medical Students in a Premier Medical School in India

Background

As preventing cancer with the help of a vaccine is a comparatively new concept, awareness and education about it will have important implication in the implementation of this strategy.

Materials and Methods

Present explorative questionnaire based survey included 618 MBBS students for final analysis.

Results

Majority of participants (89.6%) were well aware of the preventable nature of cervical cancer. Most of them (89.2%) knew that necessary factor responsible for cervical cancer is infection with high risk HPV. Awareness regarding the availability of vaccine against cervical cancer was 75.6%. Females had a better awareness regarding availability of vaccine, target population for vaccination and about the catch up program. Overall acceptance of HPV vaccine among the population studied was 67.8%. Medical teaching had a definitive impact on the understanding of this important public health issue. Females seemed to be more ready to accept the vaccine and recommend it to others. For our study population the most common source of information was medical school teaching. Majority of participants agreed that the most important obstacle in implementation of HPV vaccination program in our country is inadequate information and 86.2% wanted to be educated by experts in this regard.

Conclusion

HPV vaccine for primary prevention of cervical cancer is a relatively new concept. Health professional will be able to play a pivotal role in popularizing this strategy.     

Energy and Carbon Management Systems

This article examines an important class of information system that serves as the foundation for corporate energy and greenhouse gas (GHG) accounting: energy and carbon management systems (ECMS). Investors, regulators, customers, and employees increasingly demand that organizations provide information about their organizational energy use and GHG emissions. However, there is little transparency about how organizations use ECMS to meet such demands. To shed light on ECMS implementation and application, we collected extensive qualitative interview data from two service‐sector organizations: one that uses a spreadsheet‐based ECMS and another that implemented an ECMS provided by a third‐party vendor. Our analysis of collected data revealed numerous challenges in the areas of business processes, managerial capabilities, data capture and integration, and data quality. Though our study is built on only two organizations and requires confirmation in large‐sample surveys, we provide several recommendations for organizations regarding ECMS. We also provide suggestions for future studies to build on our tentative results.     

Creating a Fit Between BPR and IT Infrastructure: A Proposed Framework for Effective Implementation

As business imperatives change and new high-capability information technologies (IT) appear, organizations recognize the need to remain at the forefront of change by reengineering their business processes and implementing enabling responsive IT infrastructures. However, experience in this context indicates a lack of comprehension of essential elements and their mutual relationships that can contribute to the success of business-process change-implementation efforts. This article proposes a framework for managing IT for effective business-process redesign (BPR) implementation. After establishing BPR principles, components, and the relationship of BPR to some organizational and technological approaches, it presents the role and benefits of IT in BPR. The article then discusses in detail the core elements of the framework. Its theme is that an IT infrastructure that covers issues of BPR strategy development, IT strategic alignment, IT infrastructure development, IT sourcing, legacy systems reengineering, IS integration, and IS function competence is essential and critical for effective implementation.     

The COMET Handbook: version 1.0

The selection of appropriate outcomes is crucial when designing clinical trials in order to compare the effects of different interventions directly. For the findings to influence policy and practice, the outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. It is now widely acknowledged that insufficient attention has been paid to the choice of outcomes measured in clinical trials. Researchers are increasingly addressing this issue through the development and use of a core outcome set, an agreed standardised collection of outcomes which should be measured and reported, as a minimum, in all trials for a specific clinical area.Accumulating work in this area has identified the need for guidance on the development, implementation, evaluation and updating of core outcome sets. This Handbook, developed by the COMET Initiative, brings together current thinking and methodological research regarding those issues. We recommend a four-step process to develop a core outcome set. The aim is to update the contents of the Handbook as further research is identified.