Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review

ObjectivesSeveral implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied.MethodsWe searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors’ concepts of process evaluation of the included publications to those of Proctor et al.( 2010).ResultOf 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity.Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals’ viewpoint in most of the included publications, but the management viewpoint was missing.DiscussionThe conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.     

基于协同创新理念下的基础医学实验教学中心建设研究

随着国内高等医学教育管理体制改革的日益深化和素质教育的全面推进，医学院校的教学实验室建设从以往单一学科设置、传统的基础医学教学实验室逐步演变为按功能分类、按学科群布局的基础医学实验教学中心。在陆军军医大学基础医学实验教学中心建设过程中，从构建“大中心”、创建实验教学课程新体系、探索创新实践教育新模式、创建优秀实验教师队伍等方面进行了实践探索，相关工作为今后实验教学中心的建设提供了实践参考。     

Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review

ObjectiveWe conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome).Data SourcesMEDLINE, Embase, reference lists, and targeted websites.Study SelectionTwo independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice.Data ExtractionTwo reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text.Data SynthesisUsing basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes.ConclusionsImplementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.     

Disrupting the System: An Innovative Model of Comprehensive Care

Despite health care reform, our nation continues to struggle containing health care costs while meeting the needs of persons with behavioral health disorders and comorbid chronic care conditions. The purpose of this article is to propose that dually certified primary care and psychiatric mental health nurse practitioners may be the disruptive innovation that becomes the solution for improving the coordination and care for high-need patients while containing costs. The concepts of disruptive innovation, integrated care, and whole person care are discussed followed by an introduction to the innovative primary care and psychiatric mental health nurse practitioner’s role and its potential for health care system disruption. Finally, a call to nursing is proffered to seize current opportunities to meet the Triple Aim challenge by providing whole person care that is high-quality, cost-effective, and satisfactory to patients because it is truly patient centered and meets their needs.     

吴澄《不居集》学术思想撷要

《不居集》是清代著名新安医家吴澄的代表著作。本文对吴澄《不居集》的学术思想进行了分析与总结,集中体现其阐述的虚损病统治大法,提出了虚损病的嗽、热、痰、血四大证,指出治虚损之痰三法即培脾、保肺、补肾,总结了血证八法合八卦及治未病思想。该书的遣方用药及论证详明清晰,既总结前贤治虚之旨,又结合自身临证之体验,开阔了虚损病辨证诊疗的思路,体现了新安医学的思想传承,其学术思想对后世医家及中医虚损理论的创新与发展具有较大的指导意义。     

Methods for Early Assessment of the Societal Value of Health Technologies: A Scoping Review and Proposal for Classification

ObjectivesEarly assessments of health technologies help to better align and integrate their development and assessment. Such assessments can take many forms and serve different purposes, hampering users in their selection of the most appropriate method for a specific goal. The aim of this scoping review was to structure the large set of methods according to their specific goal.MethodsA scoping review was conducted using PubMed and reference lists of retrieved articles, to identify review studies with a methodological focus. From the included reviews, all individual methods were listed. Based on additional literature and examples, we extracted the specific goal of each method. All goals were clustered to derive a set of subclasses and methods were grouped into these subclasses.ResultsOf the 404 screened, 5 reviews were included, and 1 was added when searching reference lists. The reviews described 56 methods, of which 43 (77%) were included and classified as methods to (1) explore the nature and magnitude of the problem, (2) estimate the nature and magnitude of the expected (societal) value, (3) identify conditions for the potential value to materialize, and (4) help develop and design the type of research that is needed.ConclusionsThe wide range of methods for exploring the societal value of health technologies at an early stage of development can be subdivided into a limited number of classes, distinguishing methods according to their specific objective. This facilitates selection of appropriate methods, depending on the specific needs and aims.