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Cluster-randomized Trial (cluster-randomized + trial)
Selected AbstractsPatient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysisDIABETIC MEDICINE, Issue 2 2006R. F. Dijkstra Abstract Aims Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. Patients and methods In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. Results Glycated haemoglobin (HbA1c) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. Conclusion Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings. [source] Evaluation of the Implementation of Nursing Diagnoses, Interventions, and OutcomesINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 1 2009Maria Müller-Staub PhD PURPOSE.,This paper aims to provide insight into nursing classifications and to report the effects of nursing diagnostics implementation. This paper summarizes the results of six studies. METHODS.,Two systematic reviews, instrument development and testing, a pre,post intervention study, and a cluster-randomized trial were performed. FINDINGS.,The NANDA International classification met most of the literature-based classification criteria, and results showed the Quality of Nursing Diagnoses, Interventions and Outcomes (Q-DIO) to be a reliable instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes. Implementation of standardized nursing language significantly improved the quality of documented nursing diagnoses, related interventions, and patient outcomes. As a follow-up measure, Guided Clinical Reasoning (GCR) was effective in supporting nurses' clinical reasoning skills. CONCLUSIONS.,Carefully implementing classifications led to enhanced, accurately stated nursing diagnoses, more effective nursing interventions, and better patient outcomes. IMPLICATIONS.,Rethinking implementation methods for standardized language and using GCR is recommended. Based on the results of this study, the inclusion of NANDA International diagnoses with related interventions and outcomes in electronic health records is suggested. [source] Antibiotic Prescriptions Are Associated with Increased Patient Satisfaction With Emergency Department Visits for Acute Respiratory Tract InfectionsACADEMIC EMERGENCY MEDICINE, Issue 10 2009Cordelia R. Stearns Abstract Objectives:, Health care providers cite patient satisfaction as a common reason for prescribing antibiotics for viral acute upper respiratory infections (URIs), even though quality performance measures emphasize nonantibiotic treatment for these conditions. In a secondary analysis of a cluster-randomized trial to test a combined patient and physician educational intervention to reduce antibiotic prescribing for URIs, the authors examined whether satisfaction is greater among patients diagnosed with URIs who are prescribed antibiotics in emergency department (ED) settings. Methods:, This was a follow-up telephone survey of 959 patients who received care for acute respiratory infections at any of eight Veterans Administration (VA) hospital EDs or eight location-matched non-VA hospital EDs around the United States. Patients reported their satisfaction with the amount of time spent in the ED, the explanation of treatment, the provider treatment, and overall satisfaction on a five-point Likert scale. The primary measure of effect was the association between antibiotic prescription and visit satisfaction, adjusted for patient and visit characteristics. Results:, Antibiotic treatment was significantly associated with increased overall visit satisfaction in non-VA EDs (adjusted odds ratio [OR] = 1.97, 95% confidence interval [CI] = 1.23 to 3.17), but not VA EDs (adjusted OR = 1.13, 95% CI = 0.81 to 1.58). Patients managed in non-VA EDs who received antibiotics were also significantly more likely to be satisfied with the explanation of treatment and the manner in which they were treated by the provider. Conclusions:, Antibiotic prescriptions are associated with increased overall patient satisfaction in non-VA, but not VA, ED visits for URIs. Continued efforts to reduce unnecessary prescriptions in these settings must address ways to maintain patient satisfaction and still reduce antibiotic prescriptions. [source] Standardized discharge orders after stroke: Results of the quality improvement in stroke prevention (QUISP) cluster randomized trial,ANNALS OF NEUROLOGY, Issue 5 2010S. Claiborne Johnston MD Objective Proven strategies to reduce risk of stroke recurrence are under-utilized. We sought to evaluate the impact of standardized stroke discharge orders on treatment practices in a cluster-randomized trial. Methods The Quality Improvement in Stroke Prevention (QUISP) trial randomized 12 hospitals to continue usual care or to receive assistance in the development and implementation of standardized stroke discharge orders. All patients with ischemic stroke were identified during a 12-month period prior to implementation and for 12 months afterward, and were followed for 6 months after discharge. The primary outcome was optimal treatment at 6 months, defined as taking a statin, having blood pressure <140/90mmHg, and receiving anticoagulation if atrial fibrillation was diagnosed. The primary analysis treated the hospital as the unit of analysis, comparing optimal treatment rates,adjusted for race, age, dementia, atrial fibrillation, and history of bleeding,between intervention and non-intervention hospitals using a paired t test. Results In the primary analysis with hospital as the unit of analysis, the odds of optimal treatment was not significantly increased at intervention compared to non-intervention hospitals (odds ratio, 1.39; 95% confidence interval, 0.71,2.76; p = 0.27). However, in analyses conducted at the level of the individual patients (N = 3,361), rates of optimal treatment increased from 37% to 45% in the intervention hospitals (p = 0.001) and did not change significantly in the non-intervention hospitals (39% to 40%; p = 0.27). Interpretation Implementation of standardized discharge orders after stroke was associated with increased rates of optimal secondary prevention; this improvement was not significant in the primary analysis at the hospital level. ANN NEUROL 2010;67:579,589 [source] | ||||||||||