Background
Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce ...healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.
Objectives
To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face‐to‐face care, or telephone consultation).
Search methods
We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.
Selection criteria
We considered randomised controlled trials of interactive TM that involved direct patient‐provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self‐management TM interventions.
Data collection and analysis
For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta‐analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.
Main results
We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.
The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).
Telemedicine provided remote monitoring (55 studies), or real‐time video‐conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self‐management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real‐time assessment of clinical status, for example post‐operative assessment after minor operation or follow‐up after solid organ transplantation (8) vi), screening, for angina (1).
The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e‐mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.
We found no difference between groups for all‐cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I2 = 44%) (moderate to high certainty of evidence) at a median of six months follow‐up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow‐up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:‐4.39, 95% CI ‐7.94 to ‐0.83; P < 0.02; I2 = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow‐up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD ‐0.31, 95% CI ‐0.37 to ‐0.24; P < 0.00001; I2= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow‐up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD ‐12.45, 95% CI ‐14.23 to ‐10.68; P < 0.00001; I2 = 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:‐4.33, 95% CI ‐5.30 to ‐3.35, P < 0.00001; I2 = 17%; DBP: ‐2.75 95% CI ‐3.28 to ‐2.22, P < 0.00001; I2 = 45% (moderate certainty evidence), in TM as compared with usual care.
Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video‐conferencing, as compared to face‐to‐face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.
Authors' conclusions
The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face‐to‐face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.
Summary
The aim of this overview of systematic reviews was to summarize evidence from up‐to‐date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in ...adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual‐oriented and school‐based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar‐sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.
Disease surveillance is an essential public health function needed to prevent, detect, monitor and respond to health threats. Integrated disease surveillance (IDS) enhances its utility and has been ...advocated for decades by the World Health Organization. This study sought to examine the state of IDS implementation worldwide.
The study used a concurrent mixed methods approach consisting of a systematic scoping review of the literature on IDS, a survey of International Association of National Public Health Institutes (IANPHI) members and qualitative deep dive case studies in seven countries.
This report collates, analyses and synthesises the findings from the three components. The scoping review consisted of a review of summarised evidence on IDS. Eight reviews and five primary studies were included. The cross-sectional survey was conducted of 110 IANPHI members representing ninety-five countries. Qualitative case studies were conducted in Malawi, Mozambique, Uganda, Pakistan, Canada, Sweden, and England, which involved thirty-four focus group discussions and forty-eight key informant interviews.
In the different countries, IDS is conceptualised differently and there are differing levels of maturity of IDS functions. Although the role of National Public Health Institutes has not been well defined in the IDS, they play a significant role in IDS in many countries. Fragmentation between sectors and resourcing (human and financial) issues were common. Good governance measures such as appropriate legislative and regulatory frameworks and roles and responsibilities for IDS were often unclear. The COVID-19 pandemic has strengthened some surveillance systems, often through leveraging existing respiratory surveillance systems. In some instances, improvements were seen only for COVID-19 related data but these changes were not sustained. Evaluation of IDS was also reported to be weak.
Integration should be driven by a clear purpose and contextualised. Political commitment, clear governance, and resourcing are needed. Technology and the establishment of technical communities of practice may help. However, the complexity and cost of integration should not be under-estimated, and further economic and impact evaluations of IDS are needed.
Background
Healthcare‐associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs ...are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.
Objectives
To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device‐related infection rates and measures of adherence.
Search methods
We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of s of Reviews of Effectiveness (DARE) for related reviews.
Selection criteria
We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device‐related infections.
Data collection and analysis
Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.
Main results
We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line‐associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator‐associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.
The largest median effect on rates of VAP was found at nine months follow‐up with a decrease of 7.36 (‐10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (‐22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (‐6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta‐analyses, but due to very high statistical heterogeneity among included studies (I2 up to 97%), we did not retain these analyses. Six of the included studies reported post‐intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow‐up was a decrease of 0.6 (‐2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow‐up times.
Authors' conclusions
The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.
Organisational culture is an anthropological metaphor used to inform research and consultancy and to explain organisational environments. In recent years, increasing emphasis has been placed on the ...need to change organisational culture in order to improve healthcare performance. However, the precise function of organisational culture in healthcare policy often remains underspecified and the desirability and feasibility of strategies to be adopted have been called into question. The objective of this review was to determine the effectiveness of strategies to change organisational culture in order to improve healthcare performance.
We searched the following electronic databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Sociological Abstracts, Web of Knowledge, PsycINFO, Business and Management, EThOS, Index to Theses, Intute, HMIC, SIGLE, and Scopus until October 2009. The Database of Abstracts of Reviews of Effectiveness (DARE) was searched for related reviews. We also searched the reference lists of all papers and relevant reviews identified, and we contacted experts in the field for advice on further potential studies. We considered randomised controlled trials (RCTs) or well designed quasi-experimental studies (controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series (ITS) analyses). Studies could be set in any type of healthcare organisation in which strategies to change organisational culture in order to improve healthcare performance were applied. Our main outcomes were objective measures of professional performance and patient outcome.
The search strategy yielded 4,239 records. After the full text assessment, two CBA studies were included in the review. They both assessed the impact of interventions aimed at changing organisational culture, but one evaluated the impact on work-related and personal outcomes while the other measured clinical outcomes. Both were at high risk of bias. Both reported positive results.
Current available evidence does not identify any effective, generalisable strategies to change organisational culture. Healthcare organisations considering implementing interventions aimed at changing culture should seriously consider conducting an evaluation (using a robust design, e.g., ITS) to strengthen the evidence about this topic.
The champion model is increasingly being adopted to improve uptake of guideline-based care in long-term care (LTC). Studies suggest that an on-site champion may improve the quality of care residents' ...health outcomes. This review assessed the effectiveness of the champion on staff adherence to guidelines and subsequent resident outcomes in LTC homes.
This was a systematic review and meta-analyses of randomised controlled trials. Eligible studies included residents aged 65 or over and nursing staff in LTC homes where there was a stand-alone or multi-component intervention that used a champion to improve staff adherence to guidelines and resident outcomes. The measured outcomes included staff adherence to guidelines, resident health outcomes, quality of life, adverse events, satisfaction with care, or resource use. Study quality was assessed with the Cochrane Risk of Bias tool; evidence certainty was assessed using the GRADE approach.
After screening 4367 citations, we identified 12 articles that included the results of 1 RCT and 11 cluster-RCTs. All included papers evaluated the effects of a champion as part of a multicomponent intervention. We found low certainty evidence that champions as part of multicomponent interventions may improve staff adherence to guidelines. Effect sizes varied in magnitude across studies including unadjusted risk differences (RD) of 4.1% 95% CI: - 3%, 9% to 44.8% 95% CI: 32%, 61% for improving pressure ulcer prevention in a bed and a chair, respectively, RD of 44% 95% CI: 17%, 71% for improving depression identification and RD of 21% 95% CI: 12%, 30% for improving function-focused care to residents.
Champions may improve staff adherence to evidence-based guidelines in LTC homes. However, methodological issues and poor reporting creates uncertainty around these findings. It is premature to recommend the widespread use of champions to improve uptake of guideline-based care in LTC without further study of the champion role and its impact on cost.
PROSPERO CRD42019145579 . Registered on 20 August 2019.
Background
Reporting of adverse clinical events is thought to be an effective method of improving the safety of healthcare. Underreporting of these adverse events is often said to occur with ...consequence of missing of opportunities to learn from these incidents. A clinical incident can be defined as any occurrence which is not consistent with the routine care of the patient or the routine operation of the institution.
Objectives
To assess the effects of interventions designed to increase clinical incident reporting in healthcare settings.
Search methods
We searched the the following databases: Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Social Science Citation Index and Science Citation Index (Web of Knowledge), Healthstar (OVID), INSPEC, DHSS‐DATA, SIGLE, ISI Conference Proceedings, Web of Science Conference Proceedings Citation Index (Science), Database of s of Reviews of Effectiveness (DARE).
Selection criteria
Randomised controlled trials (RCT), controlled before‐after studies (CBA) and interrupted time series (ITS) of interventions designed to increase clinical incident reporting in healthcare.
Data collection and analysis
At least two review authors assessed the eligibility of potentially relevant studies, extracted the data and assessed the quality of included studies.
Main results
Four studies (one CBA and three ITS studies) met our inclusion criteria and were included in the review. The CBA study showed a significant improvement in incident reporting rates after the introduction of the new reporting system. Just one of the ITS studies showed a statistically significant improved effectiveness of the new reporting system from nine months. The other two studies reported no statistically significant improvements.
Authors' conclusions
Because of the limitations of the studies it is not possible to draw conclusions for clinical practice. Anyone introducing a system into practice should give careful consideration to conducting an evaluation using a robust design.
Although the formal evidence base is equivocal, practical experience suggests that implementations of technology that support telemedicine initiatives can result in improved patient outcomes, better ...patient and carer experience and reduced expenditure.
To answer the questions "Is an investment in telemedicine worth it?" and "How do I make a telemedicine implementation work?"
Summary of systematic review evidence and an illustrative case study. Discussion of implications for industry and policy.
Realisation of telemedicine benefits is much less to do with the technology itself and much more around the context of the implementing organisation and its ability to implement.
We recommend that local organisations consider deployment of telemedicine initiatives but with a greater awareness of the growing body of implementation best practice. We also recommend, for the NHS, that the centre takes a greater role in the collation and dissemination of best practice to support successful implementations of telemedicine and other health informatics initiatives.
Epidemiological research provides strong evidence for a link between repetitive work (RW) and the development of chronic trapezius myalgia (TM). The aims were to further elucidate if an accumulation ...of sensitising substances or impaired oxygenation is evident in painful muscles during RW. Females with TM (n=14) were studied during rest, 30 minutes RW and 60 minutes recovery. Microdialysate samples were obtained to determine changes in intramuscular microdialysate (IMMD) glutamate, PGE2, lactate, and pyruvate (i.e., concentration) relative to work. Muscle oxygenation (%StO2) was assessed using near-infrared spectroscopy. During work, all investigated substances, except PGE2, increased significantly: glutamate (54%, P<.0001), lactate (26%, P<.005), pyruvate (19%, P<.0001), while the %StO2 decreased (P<.05). During recovery PGE2 decreased (P<.005), lactate remained increased (P<.001), pyruvate increased progressively (P<.0001), and %StO2 had returned to baseline. Changes in substance concentrations and oxygenation in response to work indicate normal increase in metabolism but no ongoing inflammation in subjects with TM.
Both physical as well as mental demands result in an increased activity in the sympathetic nervous system (SNS) with changes in blood-pressure and heart-rate. Through local release of catecholamines, ...e.g. noradrenaline (NAd) SNS exerts various actions at the muscle level. The aims of this study were to investigate the effects of low-load repetitive work alone and in combination with mental demands on local muscle interstitial noradrenaline concentration NAd
i
, muscle activity and oxygenation, assessed with microdialysis
,
surface electromyography, and near-infrared spectroscopy, respectively. Healthy females (
n
= 15) were exposed to (1) 30 min repetitive work (RW) and (2) 30 min repetitive work with superimposed mental load (RWML) on two different occasions. Muscle NAd
i
and muscle activity increased significantly in response to RW, but did not increase further during RWML. For RW, NAd
i
was found to be inversely correlated to muscle activity. Oxygenation decreased significantly during work, independently of occasion. Our findings indicate that low-load work causes significantly increased trapezius muscle NAd
i
in healthy females, and short periods of superimposed mental load do not add to this increase and further, that both muscle activity and oxygenation were unaffected by the superimposed mental load.
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