The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop
The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop
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DOI：
10.1186/s12913-019-4063-8
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发表时间：
2019-04-29
影响因子：
2.8
通讯作者：
Leff, Bruce
中科院分区：
文献类型：
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作者：
Siu, Albert L.;Zimbroff, Robert M.;Leff, Bruce
背景将循证干预措施从研究条件转化为实际操作必然需要适应。我们实施了循证的家庭医院(HAH)干预，并评估了适应是否可以避免电压下降(在比研究中更不同的条件下应用干预时减少的好处)或程序漂移。(因偏离研究方案而产生的利益减少)。方法患者在6个月的试验期内登记参加卫生保健机构，然后进行9个季度的实施活动。该计划保留了原始循证HAH模型的核心组成部分，但在最初和整个实施过程中进行了调整。这些改编的编码是关于谁制作了它们，修改了什么，为谁进行了改编，以及改编的性质。我们收集了关于住院时间(LOS)、30天再入院和急诊科(ED)就诊、医院病情升级以及患者护理评级的信息。结果通过入院的季度进行评估。选定的结果被跟踪并反馈给项目领导。在最初6个月的试验阶段之后，我们使用Logistic回归或线性回归方法，将一个自变量包含在注册的数字季度中。根据季节和患者特征控制的模型。结果在整个实施期间进行了调整。改编的性质最常见的是增加或替换新的节目元素。295名患者接受了卫生署的替代住院服务(平均每季33人，范围为11-44人)。从计划开始起季度效应对于升级(OR 1.09，95%CI 1.01至1.18，p=0.03)很小，但对于LOS(-0.007天/季度；SE 0.02，p=0.75)、30天急诊室就诊(OR 0.93，95%CI 0.86至1.01，p=0.09)、30天再住院(OR 1.00，95%CI 0.93至1.08，p=0.99)或患者对整体医院护理的评分(OR为最高总体评分0.99，95%CI 0.93至1.05，p=0.66)。我们的发现表明，适应循证计划可能会避免由于潜在的程序漂移或电压下降而减少的益处。试验登记不适用。这项研究不是国际医学期刊编辑委员会(ICMJE)定义的临床试验，因为它是一项观察性研究，其中医疗干预的分配不是研究人员的自由裁量权。
BackgroundTranslating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from voltage drop (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or program drift. (decreased benefit arising from deviations from study protocols).MethodsPatients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics.ResultsAdaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11-44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p=0.03), but no effect was observed for LOS (-0.007days/quarter; SE 0.02, p=0.75), 30day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p=0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p=0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p=0.66).ConclusionsWe made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential program drift' or voltage drop.'Trial registrationNot applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study in which the assignment of the medical intervention is not at the discretion of the investigator.