Emerging health and social policy considerations for safe and quality end-of-life care in Australia - the evidence, gaps and challenges.

Recognition of the importance of end-of-life care will enable improvements in the quality of care delivered to patients and their families. Australia is experiencing an increasing number of deaths, (many expected), with an aging population who are living longer, often with multimorbidity. This makes end of life care a priority. The last year of someone's life takes place in a complex healthcare system, with increasing pressures on care delivery, placing the spotlight on health service providers to ensure that teams and individuals are supported and enabled to provide such care. Two rapid literature reviews identified best practice principles and processes for delivering safe and high-quality end-of-life care in acute care, aged care and community settings. The reviews identified that end-of-life care is experienced within the whole health and social care system, including hospital admissions interspersed with care in the community, outpatient and emergency department visits and potentially admission to a hospice. Much of this last year of life is spent at home, which may be a personal residence, an aged care facility, prison, supported accommodation or even on the streets. Transitions across settings requires seamless care, as well as organisational readiness to deliver safe and culturally appropriate care. This is more important now with end-of-life care subject to quality assurance mechanisms within the National Safety and Quality Health Service Standards (2nd edn): Comprehensive care. This requires all sectors to work collaboratively when caring for someone at the end of their life in order to see positive changes in care outcomes.

Managing multimorbidity: a qualitative study of the Australian general practitioner experience.

BACKGROUND: Multimorbidity is prevalent in general practice and general practitioners internationally report challenges in its management. Understanding the perspectives of general practitioners at the frontline of care is important for system sustainability and accessibility as populations age. OBJECTIVE: To explore Australian general practitioner perspectives on managing multimorbidity, the factors supporting their work, and those impeding their ability to meet their own standards of care provision. METHOD: A qualitative study conducted with Australian general practitioners using semistructured, in-depth interviews and inductive thematic data analysis. RESULTS: Twelve interviews with general practitioners were conducted. Three main themes were constructed from the data: Multimorbidity as an encounter with complexity and contingency; Evidence constraints in multimorbidity care; and Concerns for patient safety. System structure and the Australian general practice model restrict general practitioners' ability to provide care to their level of satisfaction by linking short consultation times to practice remuneration. Attitudes toward the applicability of guideline evidence were mixed despite most general practitioners questioning its generalizability. Patient safety concerns pervaded most interviews and largely centered on system fragmentation and insufficient intersectoral communication. General practitioners rely on multiple sources of information to provide patient-centered care but chiefly the accumulated knowledge of their patients. CONCLUSIONS: Australian general practitioners share many multimorbidity concerns with international colleagues. While multimorbidity-specific evidence may be unrealistic to expect in the immediate term, system investment and adaptation is needed to support general practice sustainability and clinician ability to provide adequate multimorbidity care, suitably remunerated, into the future.

Corrigendum to: Multimorbidity through the lens of life-limiting illness: how helpful are Australian clinical practice guidelines to its management in primary care?

This study assessed Australian clinical practice guidelines for life-limiting index conditions for the extent to which they acknowledged comorbidities and framed management recommendations within the context of older age and reduced life expectancy. A comprehensive search identified current, evidence-based Australian guidelines for chronic life-limiting conditions directed at general practitioners. Guideline content was analysed qualitatively before comorbidity acknowledgements were quantified using a 17-item checklist. Full guidelines were quality appraised using AGREE-II. Ten documents covering chronic obstructive pulmonary disease, heart failure, cancer pain, dementia and palliative care in aged care were identified. Most guidelines addressed one 'comorbid' condition and prompted clinicians to consider patient quality of life and personal preferences. Fewer addressed burden of treatment and half suggested modifying treatments to account for limited life expectancy, age or time horizon to benefit. Half warned of potential adverse drug interactions. Guidelines were of moderate to very high quality. Guidelines naturally prioritised their index condition, directing attention to only the most common comorbidities. However, there may be scope to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the 'guiding principles' approach now emerging internationally from organisations such as the American Geriatrics Society in response to increasing multimorbidity prevalence and evidence limitations.

Palliative care providers' use of digital health and perspectives on technological innovation: a national study.

BACKGROUND: While the need for digital health capability and technological innovation in palliative care services is growing rapidly, relatively little is known about the current uptake and views of individual palliative care practitioners. This study aims to explore palliative care practitioners' current use of and perspectives on digital health innovation in palliative care. METHODS: A descriptive cross-sectional survey with a web-based questionnaire was used. Participants were multidisciplinary palliative care practitioners in Australia. RESULTS: Surveys were returned by 170 medical, nursing, and allied health practitioners working in palliative care. Most respondents reported using a variety of digital health technology associated with clinical information systems, mobile devices, SMS text messaging, teleconferencing, and Wi-Fi. These technologies were used for the purpose of communicating with other health professionals, accessing web-based or mobile health palliative care resources, collecting or managing patient data, and providing information or education. However, few reported electronic access to patients' advance care planning documentation or could update these data. Respondents were moderately confident in their ability to use digital health, held positive beliefs that palliative care could be enhanced through digital health, and were generally supportive of ongoing innovation through digitally-enable models of care. Palliative care providers would most like to see digital health innovations in the areas of client health records, telehealth, and personal health tracking. CONCLUSION: This is the first national study of digital health in Australian palliative care providers. It contributes new knowledge in this important area of palliative care practice to guide policy and education, whilst informing future directions for research.

Knowledge to action: a scoping review of approaches to educate primary care providers in the identification and management of routine sleep disorders.

STUDY OBJECTIVES: The referral burden on health care systems for routine sleep disorders could be alleviated by educating primary care providers (PCPs) to diagnose and manage patients with sleep health issues. This requires effective professional education strategies and resources. This scoping review examined the literature on existing approaches to educate PCPs in sleep health management. METHODS: A comprehensive literature search was conducted across 8 databases to identify citations describing the education of PCPs in diagnosing and managing sleep disorders, specifically insomnia and sleep apnea. A conceptual framework, developed from the knowledge-to-action cycle, was used to analyze citations from a knowledge translation perspective. RESULTS: Searches identified 616 unique citations and after selection criteria were applied, 22 reports were included. Reports spanning 38 years were analyzed using components of the knowledge-to-action cycle to understand how educational interventions were designed, developed, implemented, and evaluated. Interventions involved didactic (32%), active (18%), and blended (41%) approaches, using face-to-face (27%), technology-mediated (45%), and multimodal (5%) delivery. Educational effectiveness was assessed in 73% of reports, most commonly using a pre/post questionnaire (41%). CONCLUSIONS: While this scoping review has utility in describing existing educational interventions to upskill PCPs to diagnose and manage sleep disorders, the findings suggest that interventions are often developed without explicitly considering the evidence of best educational practice. Future interventional designs may achieve greater sustained effectiveness by considering characteristics of the target audience, the pedagogical approaches best suited to its needs, and any environmental drivers and barriers that might impede the translation of evidence into practice. CITATION: King S, Damarell R, Schuwirth L, Vakulin A, Chai-Coetzer CL, McEvoy RD. Knowledge to action: a scoping review of approaches to educate primary care providers in the identification and management of routine sleep disorders. J Clin Sleep Med. 2021;17(11):2307-2324.

Multimorbidity through the lens of life-limiting illness: how helpful are Australian clinical practice guidelines to its management in primary care?

This study assessed Australian clinical practice guidelines for life-limiting index conditions for the extent to which they acknowledged comorbidities and framed management recommendations within the context of older age and reduced life expectancy. A comprehensive search identified current, evidence-based Australian guidelines for chronic life-limiting conditions directed at general practitioners. Guideline content was analysed qualitatively before comorbidity acknowledgements were quantified using a 17-item checklist. Full guidelines were quality appraised using AGREE-II. Ten documents covering chronic obstructive pulmonary disease, heart failure, cancer pain, dementia and palliative care in aged care were identified. Most guidelines addressed one 'comorbid' condition and prompted clinicians to consider patient quality of life and personal preferences. Fewer addressed burden of treatment and half suggested modifying treatments to account for limited life expectancy, age or time horizon to benefit. Half warned of potential adverse drug interactions. Guidelines were of moderate to very high quality. Guidelines naturally prioritised their index condition, directing attention to only the most common comorbidities. However, there may be scope to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the 'guiding principles' approach now emerging internationally from organisations such as the American Geriatrics Society in response to increasing multimorbidity prevalence and evidence limitations.

Late mortality in people with cancer: a population-based Australian study.

OBJECTIVES: To investigate causes of death of people with cancer alive five years after diagnosis, and to compare mortality rates for this group with those of the general population. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study; analysis of South Australian Cancer Registry data for all people diagnosed with cancer during 1990-1999 and alive five years after diagnosis, with follow-up to 31 December 2016. MAIN OUTCOME MEASURES: All-cause and cancer cause-specific mortality, by cancer diagnosis; standardised mortality ratios (study group v SA general population) by sex, age at diagnosis, follow-up period, and index cancer. RESULTS: Of 32 646 people with cancer alive five years after diagnosis, 30 309 were of European background (93%) and 16 400 were males (50%); the mean age at diagnosis was 60.3 years (SD, 15.7 years). The median follow-up time was 17 years (IQR, 11-21 years); 17 268 deaths were recorded (53% of patients; mean age, 80.6 years; SD, 11.4 years): 7845 attributed to cancer (45% of deaths) and 9423 attributed to non-cancer causes (55%). Ischaemic heart disease was the leading cause of death (2393 deaths), followed by prostate cancer (1424), cerebrovascular disease (1175), and breast cancer (1118). The overall standardised mortality ratio (adjusted for age, sex, and year of diagnosis) was 1.24 (95% CI, 1.22-1.25). The cumulative number of cardiovascular deaths exceeded that of cancer cause-specific deaths from 13 years after cancer diagnosis. CONCLUSIONS: Mortality among people with cancer who are alive at least five years after diagnosis was higher than for the general population, particularly cardiovascular disease-related mortality. Survivorship care should include early recognition and management of risk factors for cardiovascular disease.

Bolstering General Practitioner Palliative Care: A Critical Review of Support Provided by Australian Guidelines for Life-Limiting Chronic Conditions.

General practitioners (GPs) are increasingly expected to provide palliative care as ageing populations put pressure on specialist services. Some GPs, however, cite barriers to providing this care including prognostication challenges and lack of confidence. Palliative care content within clinical practice guidelines might serve as an opportunistic source of informational support to GPs. This review analysed palliative care content within Australian guidelines for life-limiting conditions to determine the extent to which it might satisfy GPs' stated information needs and support them to provide quality end-of-life care. Six databases and guideline repositories were searched (2011-2018). Eligible guidelines were those for a GP audience and explicitly based on an appraisal of all available evidence. Content was mapped against an established palliative care domain framework (PEPSI-COLA) and quality was assessed using AGREE-II. The nine guidelines meeting inclusion criteria were heterogenous in scope and depth of palliative care domain coverage. The 'communication' needs domain was best addressed while patient physical and emotional needs were variably covered. Spiritual, out-of-hours, terminal care and aftercare content was scant. Few guidelines addressed areas GPs are known to find challenging or acknowledged useful decision-support tools. A template covering important domains might reduce content variability across guidelines.

General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research.

BACKGROUND: General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care. METHODS: Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies. RESULTS: Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk. CONCLUSIONS: GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient's unique circumstances, and useable knowledge of each individual's capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.

Integrated Care Search: development and validation of a PubMed search filter for retrieving the integrated care research evidence.

BACKGROUND: Integrated care is an increasingly important principle for organising healthcare. Integrated care models show promise in reducing resource wastage and service fragmentation whilst improving the accessibility, patient-centredness and quality of care for patients. Those needing reliable access to the growing research evidence base for integrated care can be frustrated by search challenges reflective of the topic's complexity. The aim of this study is to report the empirical development and validation of two search filters for rapid and effective retrieval of integrated care evidence in PubMed. One filter is optimised for recall and the other for precision. METHODS: An Expert Advisory Group comprising international integrated care experts guided the study. A gold standard test set of citations was formed from screening Handbook Integrated Care chapter references for relevance. This set was divided into a Term Identification Set (20%) for determining candidate terms using frequency analysis; a Filter Development Set (40%) for testing performance of term combinations; and a Filter Validation Set (40%) reserved for confirming final filter performance. In developing the high recall filter, recall was steadily increased while maintaining precision at ≥50%. Similarly, the high precision filter sought to maximise precision while keeping recall ≥50%. For each term combination tested, an approximation of precision was obtained by reviewing the first 100 citations retrieved in Medline for relevance. RESULTS: The gold standard set comprised 534 citations. The search filter optimised for recall ('Broad Integrated Care Search') achieved 86.0-88.3% recall with corresponding low precision (47-53%). The search filter optimised for precise searching ('Narrow Integrated Care Search') demonstrated precision of 73-95% with recall reduced to between 55.9 and 59.8%. These filters are now available as one-click URL hyperlinks in the website of International Foundation for Integrated Care. CONCLUSIONS: The Broad and Narrow Integrated Care Search filters provide potential users, such as policy makers and researchers, seamless, reliable and ongoing access to integrated care evidence for decision making. These filters were developed according to a rigorous and transparent methodology designed to circumvent the challenges of information retrieval posed by this complex, multifaceted topic.

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials.

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.

Peer-supported faculty development and workplace teaching: an integrative review.

CONTEXT: The use of peer support as a faculty development technique to improve clinical teaching is uncommon in medical education, despite the benefits of situating learning in the workplace. The authors therefore conducted a broad search seeking theoretical and empirical literature describing peer support strategies for clinical teachers in health care workplaces. This included descriptive and non-experimental studies that are often excluded from reviews. The review aimed to identify and assess existing initiatives and to synthesise key challenges and benefits. METHODS: An integrative literature review was undertaken (2004-2017), based on searches of eight international electronic databases and targeted manual searches. Key concepts, elements and models were mapped using an iterative, constant comparative method. An evaluative framework, drawing on previous research, informed conclusions regarding the quality of evidence. RESULTS: From a pool of 5735 papers, 34 met the inclusion criteria. The majority referred to studies conducted in the USA (59%) and in the medical profession (71%). Analysis revealed a trend towards using a collaborative model (56%), voluntary participation (59%), and direct workplace observation by a peer clinician (68%). Design features of the peer support strategy were commonly reported (65%), with half providing outcome measures (56%). Few papers reported on process evaluation (15%) or evidence of programme sustainability (15%). Despite logistical and time-associated challenges, benefits accrued to individuals and the workplace, and included improved teaching practices. Embedding the peer support strategy into routine organisational practice proved effective. CONCLUSIONS: The results indicated that a workplace-based peer support model is an acceptable and effective faculty development strategy for health care clinical teachers. Conceptualising workplace-based peer support via a sociocultural model that acknowledges the significance of educational design, peers as collaborators and the importance of workplace context and culture is emphasised. Future research should focus on clarification studies informed by contemporary models of faculty development, in which factors impacting the health care workplace are considered.

Topic search filters: a systematic scoping review.

BACKGROUND: Searching for topics within large biomedical databases can be challenging, especially when topics are complex, diffuse, emerging or lack definitional clarity. Experimentally derived topic search filters offer a reliable solution to effective retrieval; however, their number and range of subject foci remain unknown. OBJECTIVES: This systematic scoping review aims to identify and describe available experimentally developed topic search filters. METHODS: Reports on topic search filter development (1990-) were sought using grey literature sources and 15 databases. Reports describing the conception and prospective development of a database-specific topic search and including an objectively measured estimate of its performance ('sensitivity') were included. RESULTS: Fifty-four reports met inclusion criteria. Data were extracted and thematically synthesised to describe the characteristics of 58 topic search filters. DISCUSSION: Topic search filters are proliferating and cover a wide range of subjects. Filter reports, however, often lack clear definitions of concepts and topic scope to guide users. Without standardised terminology, filters are challenging to find. Information specialists may benefit from a centralised topic filter repository and appraisal checklists to facilitate quality assessment. CONCLUSION: Findings will help information specialists identify existing topic search filters and assist filter developers to build on current knowledge in the field.

Finding the Integrated Care Evidence Base in PubMed and Beyond: A Bibliometric Study of the Challenges.

INTRODUCTION: Integrated care research evidence should be optimally visible and accessible to stakeholders. This study examines the contribution of specific databases to the discovery of integrated care evidence, and tests the usefulness of Medical Subject Heading (MeSH) indexing of this literature within PubMed. METHODS: We used bibliometric methods to analyse the integrated care literature indexed within six databases between 2007 and 2016. An international expert advisory group assessed the relevance of citations randomly retrieved from PubMed using MeSH term 'Delivery of Health Care, Integrated'. RESULTS: Integrated care evidence is diffuse, spread across many journals. Between 2007 and 2016, integrated care citations grew substantially, with the rate of increase highest in Embase. PubMed contributes the largest proportion of unique citations (citations not included in any of the other databases analysed), followed by Embase, PsycINFO and CINAHL. On average, expert reviewers rated 42.5% of citations retrieved by MeSH term 'Delivery of Health Care, Integrated' as relevant to integrated care. When these citations were dual reviewed, inter-rater agreement was low. CONCLUSION: MeSH terms alone are insufficient to retrieve integrated care content from PubMed. Embase and CINAHL contain unique content not found in PubMed that should not be overlooked. A validated search filter is proposed to simplify the process of finding integrated care research for clinicians, managers and decision-makers.

The association between body fat and musculoskeletal pain: a systematic review and meta-analysis.

BACKGROUND: Obesity and musculoskeletal pain are strongly related, but there is emerging evidence that body fat, not body weight, may be a better indicator of risk. There is, therefore, a need to determine if body fat is associated with musculoskeletal pain as it may improve management strategies. The aim of this systematic review was to investigate the association between body fat and musculoskeletal pain. METHODS: Seven electronic databases were searched from inception to 8th January 2018. Cross-sectional and longitudinal studies investigating the association between measures of body fat and musculoskeletal pain were included. All included articles were assessed for methodological rigour using the Epidemiology Appraisal Instrument. Standardised mean differences (SMDs) and effect estimates were pooled for meta-analysis. RESULTS: A total of 10,221 citations were identified through the database searching, which after abstract and full-text review, yielded 28 unique articles. Fourteen studies were included in the meta-analyses, which found significant cross-sectional associations between total body fat mass and widespread pain (SMD 0.49, 95% CI 0.37-0.61, p < 0.001). Individuals with low-back pain and knee pain had a higher body fat percentage than asymptomatic controls (SMD 0.34, 95% CI 0.17-0.52, p < 0.001 and SMD 0.18, 95% CI 0.05-0.32, p = 0.009, respectively). Fat mass index was significantly, albeit weakly, associated with foot pain (SMD 0.05, 95% CI 0.03-0.06, p < 0.001). Longitudinal studies (n = 8) were unsuitable for meta-analysis, but were largely indicative of elevated body fat increasing the risk of incident and worsening joint pain. There was conflicting evidence for an association between body fat percentage and incident low-back pain (3 studies, follow-up 4-20 years). Increasing knee pain (1 study) and incident foot pain (2 studies) were positively associated with body fat percentage and fat mass index. The percentage of items in the EAI graded as 'yes' for each study ranged from 23 to 85%, indicating variable methodological quality of the included studies. CONCLUSIONS: This systematic review and meta-analysis identified positive cross-sectional associations between increased body fat and widespread and single-site joint pain in the low-back, knee and foot. Longitudinal studies suggest elevated body fat may infer increased risk of incident and worsening joint pain, although further high-quality studies are required.

A Systematic Review and Meta-Analysis of Human Milk Feeding and Morbidity in Very Low Birth Weight Infants.

This systematic review and meta-analysis synthesised the post-1990 literature examining the effect of human milk on morbidity, specifically necrotising enterocolitis (NEC), late onset sepsis (LOS), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD) and neurodevelopment in infants born ≤28 weeks' gestation and/or publications with reported infant mean birth weight of ≤1500 g. Online databases including Medline, PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials were searched, and comparisons were grouped as follows: exclusive human milk (EHM) versus exclusive preterm formula (EPTF), any human milk (HM) versus EPTF, higher versus lower dose HM, and unpasteurised versus pasteurised HM. Experimental and observational studies were pooled separately in meta-analyses. Risk of bias was assessed for each individual study and the GRADE system used to judge the certainty of the findings. Forty-nine studies (with 56 reports) were included, of which 44 could be included in meta-analyses. HM provided a clear protective effect against NEC, with an approximate 4% reduction in incidence. HM also provided a possible reduction in LOS, severe ROP and severe NEC. Particularly for NEC, any volume of HM is better than EPTF, and the higher the dose the greater the protection. Evidence regarding pasteurisation is inconclusive, but it appears to have no effect on some outcomes. Improving the intake of mother's own milk (MOM) and/or donor HM results in small improvements in morbidity in this population.

A Systematic Review of the Impact of Healthcare Reforms on Access to Emergency Department and Elective Surgery Services: 1994-2014.

This systematic review sought to identify whether health care reforms led to improvement in the emergency department (ED) length of stay (LOS) and elective surgery (ES) access in Australia, Canada, New Zealand, and the United Kingdom. The review was registered in the PROSPERO database (CRD42015016343), and nine databases were searched for peer-reviewed, English-language reports published between 1994 and 2014. We also searched relevant "grey" literature and websites. Included studies were checked for cited and citing papers. Primary studies corresponding to national and provincial ED and ES reforms in the four countries were considered. Only studies from Australia and the United Kingdom were eventually included, as no studies from the other two countries met the inclusion criteria. The reviewers involved in the study extracted the data independently using standardized forms. Studies were assessed for quality, and a narrative synthesis approach was taken to analyze the extracted data. The introduction of health care reforms in the form of time-based ED and ES targets led to improvement in ED LOS and ES access. However, the introduction of targets resulted in unintended consequences, such as increased pressure on clinicians and, in certain instances, manipulation of performance data.

Knee instability as the primary cause of failure following Total Knee Arthroplasty (TKA): A systematic review on the patient, surgical and implant characteristics of revised TKA patients.

BACKGROUND: The aim of this review was to systematically assess the current evidence available regarding knee instability after TKA to identify time to failure between primary and revision TKA. In addition, we considered the patient, surgical and implant characteristics of primary TKA patients revised for knee instability, and investigated methods used for knee instability diagnosis. METHODS: A systematic search of six databases and the unpublished literature was performed. Studies referring to instability in post-operative primary TKA patients, reporting on revision TKA due to instability, and published or available between 2005 to 30-Mar-2015 were eligible for inclusion. Quantitative data for continuous variables were pooled in statistical meta-analyses. RESULTS: A total of 1841 unique studies were identified, 42 of which met the selection criteria and a total of 22 studies included in the review. Time to failure between primary and revision TKA was 44.7months (95% CI [33.8, 55.7]), and the weighted mean age at time of revision surgery was 67.6years (95% CI [65.38, 69.75]). A gender distribution was identified, with approximately 16.4% more females revised for instability, however this was unable to be corrected for the baseline population. The majority of studies used a combination of radiographic and clinical testing to diagnose knee instability. CONCLUSION: Research on knee instability following primary TKA reported early failure and subsequent revision knee surgery. The need for revision due to instability was frequently reported in a younger patient cohort and most commonly in female TKA patients. Early revision at a younger age highlights the severe implications of an unstable knee.

How Do Clinicians Learn About Knowledge Translation? An Investigation of Current Web-Based Learning Opportunities.

BACKGROUND: Clinicians are important stakeholders in the translation of well-designed research evidence into clinical practice for optimal patient care. However, the application of knowledge translation (KT) theories and processes may present conceptual and practical challenges for clinicians. Online learning platforms are an effective means of delivering KT education, providing an interactive, time-efficient, and affordable alternative to face-to-face education programs. OBJECTIVE: This study investigates the availability and accessibility of online KT learning opportunities for health professionals. It also provides an analysis of the types of resources and associated disciplines retrieved by a range of KT synonyms. METHODS: We searched a range of bibliographic databases and the Internet (Google advanced option) using 9 KT terms to identify online KT learning resources. To be eligible, resources had to be free, aimed at clinicians, educational in intent, and interactive in design. Each term was searched using two different search engines. The details of the first 100 websites captured per browser (ie, n=200 results per term) were entered into EndNote. Each site was subsequently visited to determine its status as a learning resource. Eligible websites were appraised for quality using the AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) tool. RESULTS: We identified 971 unique websites via our multiple search strategies. Of these, 43 were health-related and educational in intent. Once these sites were evaluated for interactivity, a single website matched our inclusion criteria (Dementia Knowledge Translation Learning Centre). CONCLUSIONS: KT is an important but complex system of processes. These processes overlap with knowledge, practice, and improvement processes that go by a range of different names. For clinicians to be informed and competent in KT, they require better access to free learning opportunities. These resources should be designed from the viewpoint of the clinician, presenting KT's multifaceted theories and processes in an engaging, interactive way. This learning should empower clinicians to contextualize and apply KT strategies within their own care settings.