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Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes.

ABSTRACT: BACKGROUND:Studies of clinical effectiveness have demonstrated the many benefits of programmes that avoid unnecessary hospitalisations. Therefore, it is imperative to examine the factors influencing implementation of these programmes to ensure these benefits are realised across different healthcare contexts and settings. Numerous factors may act as determinants of implementation success or failure (facilitators and barriers), by either obstructing or enabling changes in healthcare delivery. Understanding the relationships between these determinants is needed to design and tailor strategies that integrate effective programmes into routine practice. Our aims were to describe the implementation determinants for hospital avoidance programmes for people with chronic conditions and the relationships between these determinants. METHODS:An electronic search of four databases was conducted from inception to October 2019, supplemented by snowballing for additional articles. Data were extracted using a structured data extraction tool and risk of bias assessed using the Hawker Tool. Thematic synthesis was undertaken to identify determinants of implementation success or failure for hospital avoidance programmes for people with chronic conditions, which were categorised according to the Consolidated Framework for Implementation Research (CFIR). The relationships between these determinants were also mapped. RESULTS:The initial search returned 3537 articles after duplicates were removed. After title and abstract screening, 123 articles underwent full-text review. Thirteen articles (14 studies) met the inclusion criteria. Thematic synthesis yielded 23 determinants of implementation across the five CFIR domains. 'Availability of resources', 'compatibility and fit', and 'engagement of interprofessional team' emerged as the most prominent determinants across the included studies. The most interconnected implementation determinants were the 'compatibility and fit' of interventions and 'leadership influence' factors. CONCLUSIONS:Evidence is emerging for how chronic condition hospital avoidance programmes can be successfully implemented and scaled across different settings and contexts. This review provides a summary of key implementation determinants and their relationships. We propose a hypothesised causal loop diagram to represent the relationship between determinants within a complex adaptive system. TRIAL REGISTRATION:PROSPERO 162812.

SUBMITTER: Sarkies M

PROVIDER: S-EPMC7579904 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes.

Sarkies Mitchell M Long Janet C JC Pomare Chiara C Wu Wendy W Clay-Williams Robyn R Nguyen Hoa Mi HM Francis-Auton Emilie E Westbrook Johanna J Levesque Jean-Frédéric JF Watson Diane E DE Braithwaite Jeffrey J

Implementation science : IS 20201021 1

<h4>Background</h4>Studies of clinical effectiveness have demonstrated the many benefits of programmes that avoid unnecessary hospitalisations. Therefore, it is imperative to examine the factors influencing implementation of these programmes to ensure these benefits are realised across different healthcare contexts and settings. Numerous factors may act as determinants of implementation success or failure (facilitators and barriers), by either obstructing or enabling changes in healthcare delive ...[more]

PMID: 33087147

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Project description:Growth retardation and stress-induced premature plant senescence are accompanied by a severe yield reduction and raise a major agro-economic concern. To improve biomass and yield in agricultural crops under mild stress conditions, the survival must be changed to productivity mode. Our previous successful attempts to delay premature senescence and growth inhibition under abiotic stress conditions by autoregulation of cytokinins (CKs) levels constitute a generic technology toward the development of highly productive plants. Since this technology is based on the induction of CKs synthesis during the age-dependent senescence phase by a senescence-specific promoter (SARK), which is not necessarily regulated by abiotic stress conditions, we developed autoregulating transgenic plants expressing the IPT gene specifically under abiotic stress conditions. The Arabidopsis promoter of the stress-induced metallothionein gene (AtMT) was isolated, fused to the IPT gene and transformed into tobacco plants. The MT:IPT transgenic tobacco plants displayed comparable elevated biomass productivity and maintained growth under drought conditions. To decipher the role and the molecular mechanisms of CKs in reverting the survival transcriptional program to a sustainable plant growth program, we performed gene expression analysis of candidate stress-related genes and found unexpectedly clear downregulation in the CK-overproducing plants. We also investigated kinase activity after applying exogenous CKs to tobacco cell suspensions that were grown in salinity stress. In-gel kinase activity analysis demonstrated CK-dependent deactivation of several stress-related kinases including two of the MAPK components, SIPK and WIPK and the NtOSAK, a member of SnRK2 kinase family, a key component of the ABA signaling cascade. A comprehensive phosphoproteomics analysis of tobacco cells, treated with exogenous CKs under salinity-stress conditions indicated that >50% of the identified phosphoproteins involved in stress responses were dephosphorylated by CKs. We hypothesize that upregulation of CK levels under stress conditions desensitize stress signaling cues through deactivation of kinases that are normally activated under stress conditions. CK-dependent desensitization of environmental stimuli is suggested to attenuate various pathways of the avoidance syndrome including the characteristic growth arrest and the premature senescence while allowing normal growth and metabolic maintenance.

Project description:Growth retardation and stress-induced premature plant senescence are accompanied by a severe yield reduction and raise a major agro-economic concern. To improve biomass and yield in agricultural crops under mild stress conditions, the survival must be changed to productivity mode. Our previous successful attempts to delay premature senescence and growth inhibition under abiotic stress conditions by autoregulation of cytokinins (CKs) levels constitute a generic technology toward the development of highly productive plants. Since this technology is based on the induction of CKs synthesis during the age-dependent senescence phase by a senescence-specific promoter (SARK), which is not necessarily regulated by abiotic stress conditions, we developed autoregulating transgenic plants expressing the IPT gene specifically under abiotic stress conditions. The Arabidopsis promoter of the stress-induced metallothionein gene (AtMT) was isolated, fused to the IPT gene and transformed into tobacco plants. The MT::IPT transgenic tobacco plants displayed comparable elevated biomass productivity and maintained growth under drought conditions. To decipher the role and the molecular mechanisms of CKs in reverting the survival transcriptional program to a sustainable plant growth program, we performed gene expression analysis of candidate stress-related genes and found unexpectedly clear downregulation in the CK-overproducing plants. We also investigated kinase activity after applying exogenous CKs to tobacco cell suspensions that were grown in salinity stress. In-gel kinase activity analysis demonstrated CK-dependent deactivation of several stress-related kinases including two of the MAPK components, SIPK and WIPK and the NtOSAK, a member of SnRK2 kinase family, a key component of the ABA signaling cascade. A comprehensive phosphoproteomics analysis of tobacco cells, treated with exogenous CKs under salinity-stress conditions indicated that >50% of the identified phosphoproteins involved in stress responses were dephosphorylated by CKs. We hypothesize that upregulation of CK levels under stress conditions desensitize stress signaling cues through deactivation of kinases that are normally activated under stress conditions. CK-dependent desensitization of environmental stimuli is suggested to attenuate various pathways of the avoidance syndrome including the characteristic growth arrest and the premature senescence while allowing normal growth and metabolic maintenance.

Project description:BackgroundThe aim was to identify the most important determinants of practice for the implementation of person-centered tools which enhance work participation for patients with chronic health conditions.MethodsA mixed-method study was conducted consisting of semi-structured interviews, a focus group and a survey. Various stakeholders were involved including (representatives of) workers with chronic health conditions, insurance physicians, occupational physicians, other healthcare professionals, researchers, employers, and policymakers. The semi-structured interviews were performed to identify implementation determinants, followed by a focus group to validate resulting determinants. To conclude, a survey was conducted to select the most important implementation determinants through prioritization by ranking the order of importance. The Tailored Implementation of Chronic Diseases checklist (TICD) was used as concept-driven coding frame for the qualitative analysis of the interviews and focus group. The self-developed survey was based on the domains of the TICD. The survey was analyzed by frequency count of first ranking of determinants per and between domains of the TICD.ResultsVarious stakeholders participated (N = 27) in the interviews and focus group. The qualitative data retrieved yielded a list of determinants with additional in-depth themes according to the TICD. For the selection of the most important determinants, a survey with 101 respondents was conducted, consisting of occupational physicians, insurance physicians and workers with a chronic health condition. From the seven domains of the TICD, respondents emphasized the importance of taking into account the needs and factors associated with workers with a chronic health condition as this determinant ranked highest. Taking into account the individual needs and wishes of workers was mentioned to enable successful implementation, whereas stress of the workers was indicated to impede implementation. Other important determinants included 'being able to work with the tools' in terms of time and usability or 'cognitions, beliefs and attitudes of occupational and insurance physicians' to be able to use the tools.ConclusionThis study identified the most important determinants from the perspective of various stakeholders involved in the implementation of client-centered tools in occupational health for workers with chronic health conditions. Furthermore, by prioritizing the most important determinants, targeted implementation strategies can be developed.

Project description:OBJECTIVE:The lack of coordinated and appropriate healthcare across sectors has produced more patients for county hospitals in China. This study examined differences in patient choice between township and county hospitals for readmission after a first township hospitalisation, and the determinants that influenced this choice. DESIGN:A retrospective study of readmissions across hospitals after a first admission in township hospital. A township-township (TT) inpatient group and a township-county (TC) inpatient group were compared. A two-level logistic regression model was used to examine the determinants of choice for hospital readmission. SETTING:Data were drawn from a population-based health utilisation database for Qianjiang District, China, from 1 January 2008 to 31 December 2013. PARTICIPANTS:This study focused on readmitted patients whose first admission was in a township hospital. Readmission cases were identified as the same diagnosis (International Classification of Diseases, Tenth Revision) in a subsequent hospitalisation within 30 days. In total, 6764 readmissions had first admissions in township hospitals. PRIMARY OUTCOME MEASURES:Patient choice for hospital readmission after a first township hospitalisation. RESULTS:The TT group accounted for 62.5% (4225) and the TC group for 37.5% (2539) of readmissions in 6 years, and the proportion of TC readmissions in total inpatients increased from 1.66% to 1.89%. Readmission rates varied among towns (p<0.001). Differences between the TC and TT groups included: length of stay (LOS) of first admission (6.96 days vs 9.23 days), average interval between admissions (6.03 days vs 14.95 days) and disease category. Admission year, age, travel time to county hospital, interval between admissions, first admission LOS and disease category were determinants of choice for hospital readmission. CONCLUSIONS:Patients whose first admission was in a township hospital were more likely to be readmitted to a county hospital. A combination of first LOS and interval between admissions may be an effective identification index for TC readmission. TRIAL REGISTRATION NUMBER:ChiCTR-OOR-14005563.

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Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes.

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Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes.

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