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      How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation

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          Abstract

          Background

          Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood.

          Methods

          A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement.

          Results

          QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload.

          Conclusions

          These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

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          Most cited references40

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          Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide

          Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face to face panel meeting. The resultant 12 item TIDieR checklist (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with an explanation and elaboration for each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.
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            Comprehensive geriatric assessment for older adults admitted to hospital

            Comprehensive geriatric assessment (CGA) is a multi‐dimensional, multi‐disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co‐ordinated and integrated plan for treatment and follow‐up can be developed. This is an update of a previously published Cochrane review. We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost‐effectiveness. We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors. We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission. We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed‐effect meta‐analysis. We estimated cost‐effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality‐adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained. We included 29 trials recruiting 13,766 participants across nine, mostly high‐income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow‐up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high‐certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow‐up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high‐certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow‐up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high‐certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high‐certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from ‐0.22 to 0.35 (5 trials, 3534 participants; low‐certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP ‐144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low‐certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI ‐0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low‐certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low‐certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI ‐0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low‐certainty evidence). The probability that CGA would be cost‐effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low‐certainty evidence). Older patients are more likely to be alive and in their own homes at follow‐up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost‐effectiveness is of low‐certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting‐specific across different sectors of care are required. What is the aim of this review? The aim of this Cochrane Review was to find out if organised and co‐ordinated specialist care (known as comprehensive geriatric assessment, or CGA) can improve care provided to older people admitted to hospital. Researchers at Cochrane collected and analysed all relevant studies to answer this question and included 29 trials in the review. Key messages Giving older people who are admitted to hospital access to specialist co‐ordinated geriatric assessment (CGA) services on admission to hospital increases the chances that they will be alive in their own homes at follow‐up. What was studied in the review? Older people admitted to hospital may have multiple, complex, and overlapping problems. They are more prone to rapid loss of independence during an acute illness, leading to potential admission to a nursing home. Some of this decline might be avoided if care needs are identified appropriately and if treatment is co‐ordinated and managed. Specialist co‐ordinated care (known as comprehensive geriatric assessment, or CGA) was developed to address medical, social, mental health, and physical needs with the help of a skilled multi‐disciplinary team. The aims are to maximise recovery and to return patients to previous levels of function when possible. In hospital, CGA is carried out on a geriatric ward, or on a general ward that is visited by a specialist geriatric team. What are the main results of the review? Review authors found 29 relevant trials from nine countries that recruited 13,766 people. These studies compared CGA with routine care for patients over 65 who were admitted to hospital. Most trials evaluated CGA that was provided on a specialised hospital ward or across several wards by a mobile team. The review shows that older people who receive CGA rather than routine medical care after admission to hospital are more likely to be living at home and are less likely to be admitted to a nursing home at up to a year after hospital admission. We found no evidence that CGA reduces risk of death during follow‐up at up to a year after admission, and we noted that CGA appeared to make little or no difference in dependence (whether patients need help for everyday activities such as feeding and walking). We found too much variation in cognitive function and length of hospital stay to draw a conclusion. Uncertainty regarding the cost‐effectiveness analysis suggests that further research is needed. How up‐to‐date is this review? Review authors searched for studies that had been published up to 5 October 2016.
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              RAMESES II reporting standards for realist evaluations

              Background Realist evaluation is increasingly used in health services and other fields of research and evaluation. No previous standards exist for reporting realist evaluations. This standard was developed as part of the RAMESES II project. The project’s aim is to produce initial reporting standards for realist evaluations. Methods We purposively recruited a maximum variety sample of an international group of experts in realist evaluation to our online Delphi panel. Panel members came from a variety of disciplines, sectors and policy fields. We prepared the briefing materials for our Delphi panel by summarising the most recent literature on realist evaluations to identify how and why rigour had been demonstrated and where gaps in expertise and rigour were evident. We also drew on our collective experience as realist evaluators, in training and supporting realist evaluations, and on the RAMESES email list to help us develop the briefing materials. Through discussion within the project team, we developed a list of issues related to quality that needed to be addressed when carrying out realist evaluations. These were then shared with the panel members and their feedback was sought. Once the panel members had provided their feedback on our briefing materials, we constructed a set of items for potential inclusion in the reporting standards and circulated these online to panel members. Panel members were asked to rank each potential item twice on a 7-point Likert scale, once for relevance and once for validity. They were also encouraged to provide free text comments. Results We recruited 35 panel members from 27 organisations across six countries from nine different disciplines. Within three rounds our Delphi panel was able to reach consensus on 20 items that should be included in the reporting standards for realist evaluations. The overall response rates for all items for rounds 1, 2 and 3 were 94 %, 76 % and 80 %, respectively. Conclusion These reporting standards for realist evaluations have been developed by drawing on a range of sources. We hope that these standards will lead to greater consistency and rigour of reporting and make realist evaluation reports more accessible, usable and helpful to different stakeholders.
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                Author and article information

                Contributors
                Journal
                Age Ageing
                Age Ageing
                ageing
                Age and Ageing
                Oxford University Press
                0002-0729
                1468-2834
                July 2021
                16 February 2021
                16 February 2021
                : 50
                : 4
                : 1371-1381
                Affiliations
                School of Healthcare, University of Leeds , Leeds, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                NIHR Applied Research Collaboration - East Midlands (ARC-EM) , UK
                School of Health Sciences, City University of London , London, UK
                University Hospitals of Leicester NHS Trust , University of Leicester, Leicester, and Loughborough University, Loughborough, UK
                School of Health and Social Work, University of Hertfordshire , Hatfield, UK
                NIHR Applied Research Collaboration – East of England (ARC-EoE) , UK
                School of Medicine, University of Nottingham , Nottingham, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                NIHR Applied Research Collaboration - East Midlands (ARC-EM) , UK
                NIHR Nottingham Biomedical Research Centre , Nottingham, UK
                Faculty of Health and Life Sciences, De Montfort University , Leicester, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                Nottingham University Hospitals NHS Trust , Nottingham, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                Surrey Health Economics Centre, University of Surrey , Guildford, UK
                Surrey Health Economics Centre, University of Surrey , Guildford, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                NIHR Applied Research Collaboration - East Midlands (ARC-EM) , UK
                NIHR Nottingham Biomedical Research Centre , Nottingham, UK
                Nottingham CityCare Partnership , NHS Provider Service, Nottingham, UK
                Population Health Sciences, King’s College London , London, UK
                School of Medicine, University of Nottingham , Nottingham, UK
                NIHR Applied Research Collaboration - East Midlands (ARC-EM) , UK
                School of Health Sciences, City University of London , London, UK
                NIHR Nottingham Biomedical Research Centre , Nottingham, UK
                Author notes
                Address correspondence to: Adam L. Gordon, Room 4113 Medical School, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK. Email: adam.gordon@ 123456nottingham.ac.uk
                Article
                afab007
                10.1093/ageing/afab007
                8522714
                33596305
                c4201cba-f18c-43c2-ab50-ee93ef436b91
                © The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Page count
                Pages: 11
                Product
                Funding
                Funded by: Dunhill Medical Trust, DOI 10.13039/501100000377;
                Award ID: FOP1/0115
                Funded by: National Institutes of Health, DOI 10.13039/100000002;
                Categories
                Qualitative Paper
                AcademicSubjects/MED00280

                Geriatric medicine
                nursing homes,quality improvement,quality improvement collaboratives,health services research,primary care,older people

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