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Article ; Online: Learning health systems in primary care

Danielle M. Nash / Zohra Bhimani / Jennifer Rayner / Merrick Zwarenstein

BMC Family Practice, Vol 22, Iss 1, Pp 1-

a systematic scoping review

2021 Volume 13

Abstract: Abstract Background Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are ... ...

Abstract	Abstract Background Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. Methods We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. Results We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. Conclusions We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.
Keywords	Learning health systems ; Primary care ; Family medicine ; Systematic review ; Scoping review ; Health systems improvement ; Medicine (General) ; R5-920
Subject code	360
Language	English
Publishing date	2021-06-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Designing provider-focused implementation trials with purpose and intent

Wynne E. Norton / Kirsty Loudon / David A. Chambers / Merrick Zwarenstein

Implementation Science, Vol 16, Iss 1, Pp 1-

introducing the PRECIS-2-PS tool

2021 Volume 11

Abstract: Abstract Background First articulated by Schwartz and Lellouch (1967), randomized controlled trials (RCTs) can be conceptualized along a continuum from more explanatory to more pragmatic. The purpose and intent of the former is to test interventions ... ...

Abstract	Abstract Background First articulated by Schwartz and Lellouch (1967), randomized controlled trials (RCTs) can be conceptualized along a continuum from more explanatory to more pragmatic. The purpose and intent of the former is to test interventions under ideal contexts, and the purpose and intent of the latter is to test interventions in real-world contexts. The PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) is a validated tool that helps researchers make decisions about the elements of the trial to match the overall purpose and intent of the trial along the continuum. The PRECIS-2 tool has guided the design of hundreds of RCTs. However, a few aspects of the tool would benefit from greater clarity, including its application to provider-focused implementation trials rather than patient-focused intervention trials. Main text We describe the newly developed PRECIS-2-Provider Strategies (PRECIS-2-PS) tool, an extension of the PRECIS-2 tool, which has been adapted for trials testing provider-focused strategies. We elaborate on nine domains that can make a provider-focused trial more explanatory or more pragmatic, including eligibility, recruitment, setting, implementation resources, flexibility of provider strategies, flexibility of intervention, data collection, primary outcome, and primary analysis. We detail the complementary roles that researchers and stakeholders play in the trial design phase, with implications for generalizability of trial results to the contexts in which they are intended to be applied. Conclusions The PRECIS-2-PS tool is designed to help research and practice teams plan for provider-focused trials that reflect the overall intent and purpose of the trial. The tool has potential to help advance the science of provider-focused strategies across a range of trials, with the ultimate goal of facilitating the adoption, integration, and sustainability of provider-focused strategies outside the context of trials.
Keywords	Pragmatic trials ; Explanatory trials ; Implementation science ; Randomized controlled trials ; PRECIS ; Implementation strategies ; Medicine (General) ; R5-920
Subject code	670
Language	English
Publishing date	2021-01-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Heterogeneity in pragmatic randomised trials

Bruno Giraudeau / Agnès Caille / Sandra M. Eldridge / Charles Weijer / Merrick Zwarenstein / Monica Taljaard

BMC Medicine, Vol 20, Iss 1, Pp 1-

sources and management

2022 Volume 16

Abstract: Abstract Background Pragmatic trials aim to generate evidence to directly inform patient, caregiver and health-system manager policies and decisions. Heterogeneity in patient characteristics contributes to heterogeneity in their response to the ... ...

Abstract	Abstract Background Pragmatic trials aim to generate evidence to directly inform patient, caregiver and health-system manager policies and decisions. Heterogeneity in patient characteristics contributes to heterogeneity in their response to the intervention. However, there are many other sources of heterogeneity in outcomes. Based on the expertise and judgements of the authors, we identify different sources of clinical and methodological heterogeneity, which translate into heterogeneity in patient responses—some we consider as desirable and some as undesirable. For each of them, we discuss and, using real-world trial examples, illustrate how heterogeneity should be managed over the whole course of the trial. Main text Heterogeneity in centres and patients should be welcomed rather than limited. Interventions can be flexible or tailored and control interventions are expected to reflect usual care, avoiding use of a placebo. Co-interventions should be allowed; adherence should not be enforced. All these elements introduce heterogeneity in interventions (experimental or control), which has to be welcomed because it mimics reality. Outcomes should be objective and possibly routinely collected; standardised assessment, blinding and adjudication should be avoided as much as possible because this is not how assessment would be done outside a trial setting. The statistical analysis strategy must be guided by the objective to inform decision-making, thus favouring the intention-to-treat principle. Pragmatic trials should consider including process analyses to inform an understanding of the trial results. Needed data to conduct these analyses should be collected unobtrusively. Finally, ethical principles must be respected, even though this may seem to conflict with goals of pragmatism; consent procedures could be incorporated in the flow of care.
Keywords	Pragmatic randomised trials ; Heterogeneity ; Cluster randomised trials ; Medicine ; R
Subject code	170 ; 332
Language	English
Publishing date	2022-10-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management

Alison H. Howie / Neil Klar / Danielle M. Nash / Jennifer N. Reid / Merrick Zwarenstein

BMC Family Practice, Vol 22, Iss 1, Pp 1-

a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651]

2021 Volume 12

Abstract: Abstract Background Printed educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical ... ...

Abstract	Abstract Background Printed educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications. Methods A pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message (“outsert”) or a longer narrative article (“insert”). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians. Results We randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of ...
Keywords	Printed educational materials ; Cluster randomized controlled trial ; Pragmatic ; Knowledge translation ; Diabetes ; Medicine (General) ; R5-920
Subject code	610
Language	English
Publishing date	2021-12-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: North–south collaboration and capacity development in global health research in low- and middle-income countries – the ARCADE projects

Salla Atkins / Sophie Marsden / Vishal Diwan / Merrick Zwarenstein

Global Health Action, Vol 9, Iss 0, Pp 1-

2016 Volume 9

Abstract: Background: Research capacity enhancement is needed in low- and middle-income countries (LMICs) for improved health, wellbeing, and health systems’ development. In this article, we discuss two capacity-building projects, the African/Asian Regional ... ...

Abstract	Background: Research capacity enhancement is needed in low- and middle-income countries (LMICs) for improved health, wellbeing, and health systems’ development. In this article, we discuss two capacity-building projects, the African/Asian Regional Capacity Development (ARCADE) in Health Systems and Services Research (HSSR) and Research on Social Determinants of Health (RSDH), implemented from 2011 to 2015. The two projects focussed on providing courses in HSSR and social determinants of health research, and on developing collaborations between universities, along with capacity in LMIC universities to manage research grant submissions, financing, and reporting. Both face-to-face and sustainable online teaching and learning resources were used in training at higher postgraduate levels (Masters and Doctoral level). Design: We collated project meeting and discussion minutes along with project periodic reports and deliverables. We extracted key outcomes from these, reflected on these in discussions, and summarised them for this paper. Results: Nearly 55 courses and modules were developed that were delivered to over 920 postgraduate students in Africa, Asia, and Europe. Junior researchers were mentored in presenting, developing, and delivering courses, and in preparing research proposals. In total, 60 collaborative funding proposals were prepared. The consortia also developed institutional capacity in research dissemination and grants management through webinars and workshops. Discussion: ARCADE HSSR and ARCADE RSDH were comprehensive programmes, focussing on developing the research skills, knowledge, and capabilities of junior researchers. One of the main strengths of these programmes was the focus on network building amongst the partner institutions, where each partner brought skills, expertise, and diverse work cultures into the consortium. Through these efforts, the projects improved both the capacity of junior researchers and the research environment in Africa, Asia, and Europe.
Keywords	capacity building ; health determinants ; global health ; Public aspects of medicine ; RA1-1270
Subject code	306
Language	English
Publishing date	2016-10-01T00:00:00Z
Publisher	Taylor & Francis Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: A partial economic evaluation of blended learning in teaching health research methods

Minna Kumpu / Salla Atkins / Merrick Zwarenstein / Lungiswa Nkonki

Global Health Action, Vol 9, Iss 0, Pp 1-

a three-university collaboration in South Africa, Sweden, and Uganda

2016 Volume 10

Abstract: Background: Novel research training approaches are needed in global health, particularly in sub-Saharan African universities, to support strengthening of health systems and services. Blended learning (BL), combining face-to-face teaching with computer- ... ...

Abstract	Background: Novel research training approaches are needed in global health, particularly in sub-Saharan African universities, to support strengthening of health systems and services. Blended learning (BL), combining face-to-face teaching with computer-based technologies, is also an accessible and flexible education method for teaching global health and related topics. When organised as inter-institutional collaboration, BL also has potential for sharing teaching resources. However, there is insufficient data on the costs of BL in higher education. Objective: Our goal was to evaluate the total provider costs of BL in teaching health research methods in a three-university collaboration. Design: A retrospective evaluation was performed on a BL course on randomised controlled trials, which was led by Stellenbosch University (SU) in South Africa and joined by Swedish and Ugandan universities. For all three universities, the costs of the BL course were evaluated using activity-based costing with an ingredients approach. For SU, the costs of the same course delivered with a classroom learning (CL) approach were also estimated. The learning outcomes of both approaches were explored using course grades as an intermediate outcome measure. Results: In this contextually bound pilot evaluation, BL had substantially higher costs than the traditional CL approach in South Africa, even when average per-site or per-student costs were considered. Staff costs were the major cost driver in both approaches, but total staff costs were three times higher for the BL course at SU. This implies that inter-institutional BL can be more time consuming, for example, due to use of new technologies. Explorative findings indicated that there was little difference in students’ learning outcomes. Conclusions: The total provider costs of the inter-institutional BL course were higher than the CL course at SU. Long-term economic evaluations of BL with societal perspective are warranted before conclusions on full costs and consequences of BL in ...
Keywords	cost analysis ; education ; public health professional ; students ; public health ; blended learning ; health systems research ; Public aspects of medicine ; RA1-1270
Subject code	370
Language	English
Publishing date	2016-10-01T00:00:00Z
Publisher	Taylor & Francis Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Successes and challenges of north–south partnerships – key lessons from the African/Asian Regional Capacity Development projects

Rosanna Färnman / Vishal Diwan / Merrick Zwarenstein / Salla Atkins

Global Health Action, Vol 9, Iss 0, Pp 1-

2016 Volume 10

Abstract: Introduction: Increasing efforts are being made globally on capacity building. North–south research partnerships have contributed significantly to enhancing the research capacity in low- and middle-income countries (LMICs) over the past few decades; ... ...

Abstract	Introduction: Increasing efforts are being made globally on capacity building. North–south research partnerships have contributed significantly to enhancing the research capacity in low- and middle-income countries (LMICs) over the past few decades; however, a lack of skilled researchers to inform health policy development persists, particularly in LMICs. The EU FP7 funded African/Asian Regional Capacity Development (ARCADE) projects were multi-partner consortia aimed to develop a new generation of highly trained researchers from universities across the globe, focusing on global health-related subjects: health systems and services research and research on social determinants of health. This article aims to outline the successes, challenges and lessons learned from the life course of the projects, focusing on the key outputs and experiences of developing and implementing these two projects together with sub-Saharan African, Asian and European institution partners. Design: Sixteen participants from 12 partner institutions were interviewed. The data were analysed using thematic content analysis, which resulted in four themes and three sub-categories. These data were complemented by a review of project reports. Results: The results indicated that the ARCADE projects have been successful in developing and delivering courses, and have reached over 920 postgraduate students. Some partners thought the north–south and south–south partnerships that evolved during the project were the main achievement. However, others found there to be a ‘north–south divide’ in certain aspects. Challenges included technical constraints and quality assurance. Additionally, adapting new teaching and learning methods into current university systems was challenging, combined with not being able to award students with credits for their degrees. Conclusion: The ARCADE projects were introduced as an innovative and ambitious project idea, although not designed appropriately for all partner institutions. Some challenges were underestimated from the ...
Keywords	institutions ; partners ; students ; north–south collaboration ; global health ; course development ; Public aspects of medicine ; RA1-1270
Subject code	306
Language	English
Publishing date	2016-10-01T00:00:00Z
Publisher	Taylor & Francis Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Promoting development and uptake of health innovations

Archna Gupta / Cathy Thorpe / Onil Bhattacharyya / Merrick Zwarenstein

F1000Research, Vol

The Nose to Tail Tool [version 1; referees: 2 approved]

2016 Volume 5

Abstract: Introduction Health sector management is increasingly complex as new health technologies, treatments, and innovative service delivery strategies are developed. Many of these innovations are implemented prematurely, or fail to be implemented at scale, ... ...

Abstract	Introduction Health sector management is increasingly complex as new health technologies, treatments, and innovative service delivery strategies are developed. Many of these innovations are implemented prematurely, or fail to be implemented at scale, resulting in substantial wasted resources. Methods A scoping review was conducted to identify articles that described the scale up process conceptually or that described an instance in which a healthcare innovation was scaled up. We define scale up as the expansion and extension of delivery or access to an innovation for all end users in a jurisdiction who will benefit from it. Results Sixty nine articles were eligible for review. Frequently described stages in the innovation process and contextual issues that influence progress through each stage were mapped. 16 stages were identified: 12 deliberation and 4 action stages. Included papers suggest that innovations progress through stages of maturity and the uptake of innovation depends on the innovation aligning with the interests of 3 critical stakeholder groups (innovators, end users and the decision makers) and is also influenced by 3 broader contexts (social and physical environment, the health system, and the regulatory, political and economic environment). The 16 stages form the rows of the Nose to Tail Tool (NTT) grid and the 6 contingency factors form columns. The resulting stage-by-issue grid consists of 72 cells, each populated with cell-specific questions, prompts and considerations from the reviewed literature. Conclusion We offer a tool that helps stakeholders identify the stage of maturity of their innovation, helps facilitate deliberative discussions on the key considerations for each major stakeholder group and the major contextual barriers that the innovation faces. We believe the NTT will help to identify potential problems that the innovation will face and facilitates early modification, before large investments are made in a potentially flawed solution.
Keywords	Health Service Delivery & Management of Anesthesia ; Health Systems & Services Research ; Medicine ; R ; Science ; Q
Subject code	360
Language	English
Publishing date	2016-03-01T00:00:00Z
Publisher	F1000 Research Ltd
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Connecting artificial intelligence and primary care challenges

Bridget L Ryan / Amanda Terry / Merrick Zwarenstein / Andrew Pinto / Judith Belle Brown / Leslie Meredith / Jacqueline K Kueper / Ravninder Bahniwal / Ron Beleno / Janet Dang / Daniel Leger / Scott McKay / Daniel J Lizotte

BMJ Health & Care Informatics, Vol 29, Iss

findings from a multi stakeholder collaborative consultation

2022 Volume 1

Keywords	Computer applications to medicine. Medical informatics ; R858-859.7
Language	English
Publishing date	2022-01-01T00:00:00Z
Publisher	BMJ Publishing Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: ‘Research clinics’

Salla Atkins / Dinansha Varshney / Elnta Meragia / Merrick Zwarenstein / Vishal Diwan

Global Health Action, Vol 9, Iss 0, Pp 1-

online journal clubs between south and north for student mentoring

2016 Volume 5

Abstract: Background: Capacity development in health research is high on the agenda of many low- and middle-income countries. Objective: The ARCADE projects, funded by the EU, have been working in Africa and Asia since 2011 in order to build postgraduate students’ ...

Abstract	Background: Capacity development in health research is high on the agenda of many low- and middle-income countries. Objective: The ARCADE projects, funded by the EU, have been working in Africa and Asia since 2011 in order to build postgraduate students’ health research capacity. In this short communication, we describe one initiative in these projects, that of research clinics – online journal clubs connecting southern and northern students and experts. Design: We describe the implementation of these research clinics together with student and participant experiences. Results: From 2012 to 2015, a total of seven journal clubs were presented by students and junior researchers on topics related to global health. Sessions were connected through web conferencing, connecting experts and students from different countries. Conclusions: The research clinics succeeded in engaging young researchers across the globe and connecting them with global experts. The contacts and suggestions made were appreciated by students. This format has potential to contribute toward research capacity building in low- and middle-income countries.
Keywords	capacity building ; postgraduate education ; global health ; developing countries ; Public aspects of medicine ; RA1-1270
Subject code	028
Language	English
Publishing date	2016-10-01T00:00:00Z
Publisher	Taylor & Francis Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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