Scoping review of systematic reviews of complementary medicine for musculoskeletal and mental health conditions Do physiotherapists' attitudes towards evidence-based practice change as a result of an evidence-based educational programme? A Smartphone App to Assist Smoking Cessation Among Aboriginal Australians: Findings From a Pilot Randomized Controlled Trial Making nursing work: breaking through the role confusion of advanced practice nursing. Mobile Phone Apps for Smoking Cessation: Quality and Usability Among Smokers With Psychosis Does physiotherapy management of low back pain change as a result of an evidence-based educational programme? Effects of a co-financed interdisciplinary collaboration model in primary health care on service utilisation among patients with musculoskeletal disorders. Survey of the perceived professional, educational and personal needs of physiotherapists in primary care and community settings. Texting and Mobile Phone App Interventions for Improving Adherence to Preventive Behavior in Adolescents: A Systematic Review Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times. A single group follow-up study of non-surgical patients seen by physiotherapists working in expanded roles in orthopaedic departments: recall of recommendations, change in exercise and self-efficacy An international registry of systematic-review protocols Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances? Development and Validation of a Multidisciplinary Mobile Care System for Patients With Advanced Gastrointestinal Cancer: Interventional Observation Study Active Treatment for Idiopathic Adolescent Scoliosis (ACTIvATeS): a feasibility study. A randomized controlled trial on rehabilitation through caregiver-delivered nurse-organized service programs for disabled stroke patients in rural china (the RECOVER trial): design and rationale Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report Perceptions of Patients With Chronic Obstructive Pulmonary Disease and Their Physiotherapists Regarding the Use of an eHealth Intervention Safety and tolerability of antipsychotic polypharmacy How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? Translating Clinical Trial Results into Practice: The Effect of an AIDS Clinical Trial on Prescribed Antiretroviral Therapy for HIV-Infected Pregnant Women Perspectives on research evidence and clinical practice: a survey of Australian physiotherapists. PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies
Objective To identify potentially effective complementary approaches for musculoskeletal (MSK)–mental health ( MH ) comorbidity , by synthesis ing evidence on effectiveness , cost-effectiveness and safety from systematic review s ( SRs ) . Design Scoping review of SRs . Methods We search ed literature data bases , registries and reference lists , and contacted key authors and professional organisations to identify SRs of r and omised controlled trials for complementary medicine for MSK or MH . Inclusion criteria were : published after 2004 , study ing adults , in English and scoring > 50 % on Assessing the Method ological Quality of Systematic Review s ( AMSTAR ) ; quality appraisal checklist ) . SRs were synthesis ed to identify research priorities , based on moderate/good quality evidence , sample size and indication of cost-effectiveness and safety . Results We included 84 MSK SRs and 27 MH SRs . Only one focused on MSK – MH comorbidity . Meditative approaches and yoga may improve MH outcomes in MSK population s. Yoga and tai chi had moderate/good evidence for MSK and MH conditions . SRs reported moderate/good quality evidence ( any comparator ) in a moderate/large population for :  low back pain ( LBP )  ( yoga , acupuncture , spinal manipulation/mobilisation , osteopathy ) , osteoarthritis ( OA ) ( acupuncture , tai chi ) , neck pain  ( acupuncture , manipulation/manual therapy ) , myofascial trigger point pain ( acupuncture ) , depression ( mindfulness-based stress reduction ( MBSR ) , meditation , tai chi , relaxation ) , anxiety ( meditation/MBSR , moving meditation , yoga ) , sleep disorders ( meditative/mind – body movement ) and stress/distress ( mindfulness ) . The majority of these complementary approaches had some evidence of safety — only three had evidence of harm . There was some evidence of cost-effectiveness for spinal manipulation/mobilisation and acupuncture for LBP , and manual therapy/manipulation for neck pain , but few SRs review ed cost-effectiveness and many found no data . Conclusions Only one SR studied MSK – MH comorbidity . Research priorities for complementary medicine for both MSK and MH ( LBP , OA , depression , anxiety and sleep problems ) are yoga , mindfulness and tai chi . Despite the large number of SRs and the prevalence of comorbidity , more high- quality , large r and omised controlled trials in comorbid population s are needed RATIONALE The concept of evidence -based practice ( EBP ) encourages health care professionals to provide the most effective health care , and to be accountable for the interventions they provide . Little work has been undertaken to examine how practically allied health professionals ' encompass EBP and how they perceptive and underst and the concept of EBP . The use of opinion leaders to disseminate new evidence into practice , and thereby encourage the behaviour of health care professionals has been proposed . AIMS The aims of this study were to investigate physiotherapists ' attitudes towards EBP and to examine change in their attitudes following an education package , which utilized local opinion leaders . METHOD Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster r and omized by location of work to two groups . The intervention group received an evidence -based programme on aspects of EBP including literature search ing and critical appraisal . The attention control group received a st and ard in-service training package on the management of common knee pathologies . The physiotherapists ' attitudes towards EBP were measured at baseline ( before r and omization ) and at 3 and 6 months follow-up . RESULTS Physiotherapists reported that they primarily relied on ' courses ' and ' in-service training ' for informing their clinical practice . Most agreed that clinical practice should be based on the best available evidence and that they would change their clinical practice if evidence suggested they should do so . However , many of the physiotherapists reported difficulty in reading journals and could not identify opinion leaders in key areas . In terms of clinical practice , literature , journals and research were ascribed low priority throughout . Differences in attitudes between the intervention and control groups were observed in relation to management support for EBP at 3 and 6 months follow-up . CONCLUSIONS In this study , physiotherapists appeared to be in favour of the idea of EBP , yet they remained reluctant to change their practice . Opinion leaders were not easily identifiable by physiotherapists , suggesting that this method alone may not be an effective method of changing attitudes in clinical practice . The process of changing attitudes in the clinical environment is a complex issue worthy of further research Background Mobile health ( mHealth ) apps have the potential to increase smoking cessation , but little research has been conducted with Aboriginal communities in Australia . Objective We conducted a pilot study to assess the feasibility and acceptability and explore the effectiveness of a novel mHealth app to assist Aboriginal people to quit smoking . Methods A pilot r and omized controlled trial ( RCT ) and process evaluation comprising usage analytics data and in-depth interviews was conducted . Current Aboriginal smokers ( > 16 years old ) , who were willing to make a quit attempt in the next month , were recruited from Aboriginal Community Controlled Health Services and a government telephone coaching service . The intervention was a multifaceted And roid or iOS app comprising a personalized profile and quit plan , text and in-app motivational messages , and a challenge feature allowing users to compete with others . The comparator was usual cessation support services . Outcome data collection and analysis were conducted blinded to treatment allocation . The primary outcome was self-reported continuous smoking abstinence verified by carbon monoxide breath testing at 6 months . Secondary outcomes included point prevalence of abstinence and use of smoking cessation therapies and services . Results A total of 49 participants were recruited . Competing service delivery priorities , the lack of re sources for research , and lack of support for r and omization to a control group were the major recruitment barriers . At baseline , 23/49 ( 47 % ) of participants had tried to quit in recent weeks . At 6-month follow-up , only 1 participant ( intervention arm ) was abstinent . The process evaluation highlighted low to moderate app usage ( 3 - 10 new users per month and 4 - 8 returning users per month ) , an average of 2.9 sessions per user per month and 6.3 min per session . Key themes from interviews with intervention participants ( n=15 ) included the following : ( 1 ) the powerful influence of prevailing social norms around acceptability of smoking ; ( 2 ) high usage of mobile devices for phone , text , and social media but very low use of other smartphone apps ; ( 3 ) the role of family and social group support in supporting quit attempts ; and ( 4 ) low awareness and utilization of smoking cessation support services . Despite the broad acceptability of the app , participants also recommended technical improvements to improve functionality , greater customization of text messages , integration with existing social media platforms , and gamification features . Conclusions Smoking cessation apps need to be integrated with commonly used functions of mobile phones and draw on social networks to support their use . Although they have the potential to increase utilization of cessation support services and treatments , more research is needed to identify optimal implementation models . Robust evaluation is critical to determine their impact ; however , an RCT design may not be feasible in this setting . Trial Registration Australian and New Zeal and Clinical Trials Registry ACTRN12616001550493 ; https://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?id=371792 ( Archived by WebCite at http://www.webcitation.org/76TiV7HA6 ) AIM This paper reports a study to develop a research -informed model of the service parameters and an analysis framework for advanced practice nursing roles . BACKGROUND Changing patterns of health care are forcing service planners to examine new service delivery models . Apparent is the call for nursing service that incorporates exp and ed levels of autonomy , skill and decision-making . A number of nursing roles conform to this description under the generic title of advanced practice nurse . However , there is confusion in the health service community internationally about nomenclature , role and scope for advanced practice nursing roles . An emerging priority in response to recent developments in the nurse practitioner role is to establish service parameters for advanced practice nursing and to differentiate operationally between advanced practice and practitioner nursing roles . METHODS We conducted an interpretive , qualitative examination of the practice of a r and om sample of nine advanced practice nurses working in three acute care hospitals in south east Queensl and , Australia in 2006 . Data collection involved individual in-depth interviews , which were deductively analysed and tested against published advanced practice nursing models . RESULTS The data most comprehensively supported the Strong Model of Advanced Practice as representing the practice experiences of the research participants . This model supports definition of the service parameters and the design of an operational framework for implementation and evaluation of advanced practice nursing roles . CONCLUSION The findings differentiate advanced practice nurse and nurse practitioner roles , and offer an operational framework to identify , establish and evaluate advanced and extended nursing positions . Subject to further validation , this outcome can provide operational information for implementing innovative nursing roles appropriate to consumer needs and specific health service models Background Smoking is one of the top preventable causes of mortality in people with psychotic disorders such as schizophrenia .  Cessation treatment improves abstinence outcomes , but access is a barrier . Mobile phone apps are one way to increase access to cessation treatment ; however , whether they are usable by people with psychotic disorders , who often have special learning needs , is not known . Objective Research ers review ed 100 r and omly selected apps for smoking cessation to rate them based on US guidelines for nicotine addiction treatment and to categorize them based on app functions . We aim ed to test the usability and usefulness of the top-rated apps in 21 smokers with psychotic disorders . Methods We identified 766 smoking cessation apps and r and omly selected 100 for review . Two independent review ers rated each app with the Adherence Index to US Clinical Practice Guideline for Treating Tobacco Use and Dependence . Then , smokers with psychotic disorders evaluated the top 9 apps within a usability testing protocol . We analyzed quantitative results using descriptive statistics and t tests . Qualitative data were open-coded and analyzed for themes . Results Regarding adherence to practice guidelines , most of the r and omly sample d smoking cessation apps scored poorly—66 % rated lower than 10 out of 100 on the Adherence Index ( Mean 11.47 , SD 11.8 ) . Regarding usability , three common usability problems emerged : text-dense content , abstract symbols on the homepage , and subtle directions to edit features . Conclusions In order for apps to be effective and usable for this population , developers should utilize a balance of text and simple design that facilitate ease of navigation and content comprehension that will help people learn quit smoking skills RATIONALE The concept of evidence -based medicine is important in providing efficient health care . The process uses research findings as the basis for clinical decision making . Evidence -based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide . Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence . The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed . AIMS The aim of this study was to investigate if physiotherapists ' clinical management of patients with low back pain would change following an evidence -based education package , which utilized local opinion leaders and delivered the best evidence . METHOD Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster r and omized by location of work , to two groups . The intervention group received an evidence -based programme on the management of low back pain , including advice regarding increasing activity levels and return to normal activity and challenging patients ' fears and beliefs about their pain . The control group received a st and ard in-service training package on the management of common knee pathologies . The physiotherapists ' clinical management of patients with low back pain was measured prior to training and 6 months post training . Outcome measures were based on physiotherapists completing ' discharge summary ' question naires , which included information relating to the use and importance of therapies for treating their low back pain patients . RESULTS There were few significant differences in treatment options between the intervention and control groups post training . Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain , there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention . CONCLUSIONS Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain . This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice . Whilst there were some limitations in the overall size of the study , the results help to give an insight into the challenges faced by the health care system and research ers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care BACKGROUND In 1994 Sweden introduced a trial legislation allowing co-financing between authorities . The legislation aim ed to stimulate new ways of collaboration between health and social care providers . One of the specific objectives was to make management of patients with conditions requiring multidisciplinary care more efficient and reduce costs . This study aims to assess if there were any differences in management of patients with musculoskeletal disorders at health centres applying the trial legislation compared to health centre with conventional care with regards to health services utilisation , health care interventions received , and costs . METHOD A comparative prospect i ve study was conducted . Consecutive patients aged 16 - 64 with musculoskeletal disorders attending the health care centres with ( n=107 ) and without ( n=31 ) co-financing model were interviewed at inclusion and after 6 and 12 months . Number of contacts with professionals and interventions received were registered . RESULTS Patients at the intervention centres had significantly more contact with physiotherapists and physicians than the controls . Contacts with other services such as social insurance office , social services office or hospitals did not differ significantly between the groups . Costs were higher for the interventions centres . CONCLUSION The findings do not suggest that the trial legislation reduced health care utilisation or costs for patients with musculoskeletal disorders The emphasis of UK Government policy on primary -care-based services has led to more physiotherapists working in the community . The aims of the present study were to identify the perceived professional , educational and personal needs of community physiotherapists , and to determine good practice in meeting these needs . A survey of physiotherapists working in 15 National Health Service community trusts in the West Midl and s was carried out in September 2000 . The survey question naire was developed through focus groups and mailed to a r and om sample of 200 community physiotherapists . The response rate was 67 % , and the median age group of the respondents was 21 - 30 years . The participants worked mainly in ' urban but not inner city ' areas , most commonly in domiciliary ( 31 % , n = 38 ) and general practitioner surgery/health centre ( 26 % , n = 32 ) locations . Fifty-one per cent ( n = 66 ) of respondents had no specific learning objectives for continuing professional development ( CPD ) ; those with such objectives were more positive as to their helpfulness than those without them ( Mann-Whitney U-test z = 2.519 , P = 0.012 ) . Fifty-three per cent ( n = 68 ) also often/very often found it problematic getting cover for their caseloads so that they could take part in CPD activities . Access to library re sources and use of computers were problems , as were confidence in appraising literature and opportunities to discuss research evidence with colleagues . Fifty-nine per cent ( n = 77 ) of respondents indicated that they often/very often felt stressed by the size of their caseloads . Colleague support included mentorship , peer review , journal clubs , clinical interest groups and multidisciplinary in-service training ; respondents with experience of these re sources expressed more positive attitudes to them than those without ( Mann-Whitney U-test z = 2.871 , P < 0.0005 for each ) . Forty-two per cent ( n = 54 ) indicated that there were problems with safety issues . This study has identified needs that will have an impact on the ability of community physiotherapists to meet the dem and s of clinical governance . National Health Service management at all levels has a responsibility to facilitate the education , training and support of community physiotherapists Background Many preventable behaviors contribute to adolescent mortality and morbidity . Non-adherence to preventive measures represents a challenge and has been associated with worse health outcomes in this population . The widespread use of electronic communication technologies by adolescents , particularly the use of text messaging ( short message service , SMS ) and mobile phones , presents new opportunities to intervene on risk and preventive risk behavior , but little is known about their efficacy . Objective This study aim ed to systematic ally evaluate evidence for the efficacy of text messaging and mobile phone app interventions to improve adherence to preventive behavior among adolescents and describe intervention approaches to inform intervention development . Methods This review covers literature published between 1995 and 2015 . Search es included PubMed , Embase , CENTRAL , PsycINFO , CINAHL , INSPEC , Web of Science , Google Scholar , and additional data bases . The search strategy sought articles on text messaging and mobile phone apps combined with adherence or compliance , and adolescents and youth . An additional h and search of related themes in the Journal of Medical Internet Research was also conducted . Two review ers independently screened titles and abstract s , assessed full-text articles , and extracted data from articles that met inclusion criteria . Included studies reflect original research —experimental or preexperimental design s with text messaging or mobile phone app interventions —targeting adherence to preventive behavior among adolescents ( 12 - 24 years old ) . The preferred reporting items of systematic review s and meta-analyses ( PRISMA ) guidelines were followed for reporting results , and findings were critically appraised against the Oxford Centre for Evidence -based Medicine criteria . Results Of 1454 records , 19 met inclusion criteria , including text messaging ( n=15 ) and mobile phone apps ( n=4 ) . Studies targeted clinic attendance , contraceptive use , oral health , physical activity and weight management , sun protection , human papillomavirus ( HPV ) vaccination , smoking cessation , and sexual health .  Most studies were performed in the United States ( 47 % , 9/19 ) , included younger adolescents ( 63 % , 12/19 ) , and had sample size < 100 ( 63 % , 12/19 ) . Although most studies were r and omized controlled trials ( RCTs ; 58 % , 11/19 ) , only 5 followed an intent-to-treat analysis . Only 6 of 19 studies ( 32 % ) incorporated a theoretical framework in their design . Most studies reported good feasibility with high acceptability and satisfaction . About half of the included studies ( 42 % , 8/19 ) demonstrated significant improvement in preventive behavior with moderate st and ardized mean differences . As early efforts in this field to establish feasibility and initial efficacy , most studies were low to moderate in quality . Studies varied in sample size and methods of preventive behavior adherence or outcome assessment , which prohibited performing a meta- analysis . Conclusions Despite the promising feasibility and acceptability of text messaging and mobile phone apps in improving preventive behavior among adolescents , overall findings were modest in terms of efficacy . Further research evaluating the efficacy , effectiveness , and cost-effectiveness of these intervention approaches in promoting preventive behavior among adolescents is needed PURPOSE To examine the role of an advanced- practice physiotherapist ( APP ) with respect to ( 1 ) agreement with an orthopaedic surgeon on diagnosis and management of patients with shoulder problems ; ( 2 ) wait times ; and ( 3 ) satisfaction with care . METHODS This prospect i ve study involved patients with shoulder complaints who were referred to a shoulder specialist in a tertiary care centre . Agreement was examined on seven major diagnostic categories , need for further examination and surgery , and type of surgical procedure . Wait times were compared between the APP- and surgeon-led clinics from referral date to date of initial consultation , date of final diagnostic test , and date of confirmed diagnosis and planned treatment . A modified and vali date d version of the Visit-Specific Satisfaction Instrument assessed satisfaction in seven domains . Kappa ( κ ) coefficients and bias- and prevalence-adjusted kappa ( PABAK ) values were calculated , and strength of agreement was categorized . Wait time and satisfaction data were examined using non-parametric statistics . RESULTS Agreement on major diagnostic categories varied from 0.68 ( good ) to 0.96 ( excellent ) . Agreement with respect to indication for surgery was κ=0.75 , p<0.001 ; 95 % CI , 0.62 - 0.88 ( good ) . Wait time for APP assessment was significantly shorter than wait time for surgeon consultation at all time points ( p<0.001 ) ; the surgeon 's wait time was significantly reduced over 3 years . High satisfaction was reported in all components of care received from both health care providers . CONCLUSIONS Using experienced physiotherapists in an extended role reduces wait times without compromising patient clinical management and overall satisfaction Background Specially trained physiotherapists ( advanced practice physiotherapists ( APP ) ) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management . Little attention has been paid to the impact APPs may have on non-surgical patients . In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic , the objectives were to : 1 ) describe patients ’ recall of APP recommendations , use of self-management strategies , and barriers to management six weeks following consultation ; and , 2 ) compare exercise behaviour and self-efficacy at baseline and six weeks . Findings This was a single group pre- and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals . At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale ( response options : none , < 60 minutes/week , 1–3 hours/week or > 3 hours/week ) , and the Chronic Disease Self-efficacy Scale ( range 1–10 ; higher scores indicate higher self-efficacy ) . At follow-up participants completed questions on recall of APP recommendations , use of self-management strategies and barriers to management . Seventy three non-surgical patients with hip or knee arthritis participated , a response rate of 89 % at follow-up . Seventy one percent of patients reported that the APP recommended exercise , of whom 83 % reported exercising to manage their arthritis since the visit . Almost 50 % reported an increase in time spent stretching ; over 40 % reported an increase in time spent walking or doing strengthening exercises at follow-up . Common barriers to arthritis management were time , cost and other health problems . Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 ( p < 0.001 ) . The mean difference was 0.95 ( 95 % CI 0.43 , 1.62 ) ; the effect size was 0.51 . Conclusions This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results , particularly for enhancing use of conservative management strategies such as exercise Support for prospect i ve registration of protocol s for systematic review s has been gathering momentum . The PRISMA statement , a guideline for reporting systematic review s and meta-analyses of studies that evaluate health-care interventions , advocates registration . Well-conducted systematic review s are accepted as the best- quality evidence to inform policy and practice , and the dramatic upward trend in the number of systematic review s published annually ( fi gure ) is set to continue . However , there is currently no single facility for identifying this type of research in advance of the appearance of the results of the review . There is concern about and evidence of publication and selective outcome -reporting biases associated with systematic review s. An open registry of review s captured at the protocol stage would facilitate good practice in systematic review s by providing transparency of the review process and outcomes . Discrepancies between the methods of the published review and those planned in the registered protocol could be more readily identifi ed . Registration might also encourage full publication of the review ’s fi ndings and transparency in changes to methods that could bias fi ndings . In both the prevention and revelation of potential bias , registration should improve quality and increase confi dence that policy or practice informed by the fi ndings of systematic review s are indeed drawing on best- quality evidence . A registry of protocol s of systematic review s could assist those planning new review s and updating existing ones . Easy access to information about ongoing review s should help to optimise the use of fi nite re sources by enabling funding and commissioning agencies to avoid unnecessary duplication and encourage collaboration . A comprehensive registry could also create opportunities for method ological and other research , both within and across disciplines . Existing access to systematic - review protocol s is limited to the outputs of individual organisations , such as the Cochrane and Campbell Collaborations and the Joanna Briggs Institute . The National Public Health Service for Wales is piloting an All Wales Systematic Review s Register , but , up to now , there has been no central ised comprehensive registry of systematic - review protocol s. We are developing an international facility to register the details of ongoing systematic review s in health and social care . Our registry is being established with the existing platform and infrastructure that supports the Data base of Abstract s of Review s of Eff ects ( DARE ) , the NHS Economic Evaluations Data base ( NHS EED ) and the Health Technology Assessment ( HTA ) data base produced by the Centre for Review s and Dissemination . The initial scope of the registry will be limited to systematic review s of the eff ectiveness of health interventions . However , the longterm aim is for the registry to include details of all ongoing systematic review s with a health-related outcome in the broadest sense . Ultimately , inclusion will encompass systematic review s of health-care interventions , and review s of the social determinants of health , of service delivery , and of risk factors and genetic associations . Our web-based registry will off er free public access , be electronically search able , and open to all prospect i ve registrants . Registration will require the provision of a minimum data set , the completeness of which will be checked automatically before registration . After acceptance , the registry ’s entry and protocol for the review , if available , will be loaded on the data base as a permanent entry and a unique identifi cation number issued . An audit trail for any amendments to the information will be available within the record . Links to result ing publications will be added . These provisions ensure that the registry will match the relevant criteria required of clinical trials registries Background Role substitution is a strategy employed to assist health services manage the growing dem and for musculoskeletal care . Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic st and ards . This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinical ly and cost effective as that from an orthopaedic surgeon . Methods A double blind non-inferiority r and omized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service , from January 2013 to June 2014 . Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon . The main outcome measure was total Shoulder Pain and Disability Index ( SPADI ) score at baseline , six and 12 weeks , applying a non-inferiority margin of 15 points . Secondary outcomes tested for superiority included pain , shoulder movement , perceived improvement , adverse events , satisfaction , quality of life and costs . Results 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon , with 64 r and omised ( physiotherapist 33 , orthopaedic surgeon 31 ) . There were no significant differences in baseline characteristics between groups . Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks ( upper limit of the 95 % one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks , respectively ) . There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks . From the perspective of the health funder , the physiotherapist was less expensive . Conclusions Corticosteroid injection for shoulder pain , provided by a suitably qualified physiotherapist is at least as clinical ly effective , and less expensive , compared with similar care delivered by an orthopaedic surgeon . Policy makers and service providers should consider implementing this model of care . Trial Registration Australia and New Zeal and Clinical Trials Registry UNLABELLED Aim Integrated care pathways ( ICP ) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities . ICPs are now being implemented across international healthcare arena , but evidence to support their use is equivocal . The aim of this study was to identify the circumstances in which ICPs are effective , for whom and in what context s. Methods A systematic review of high- quality r and omised controlled trials published between 1980 and 2008 ( March ) evaluating  ICP use in child and adult population s in the full range of healthcare setting s. RESULTS 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner . This can lead to improvements in service quality and service efficiency without adverse consequences for patients . 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocol s thereby reducing variation in practice . 3 ICPs can be effective in improving documentation of treatment goals , documentation of communication with patients , carers and health professionals . 4 ICPs can be effective in improving physician agreement about treatment options . 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide . 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction , where there is scope for improvement or where roles are new . 7 Even in context s in which health professionals are already experienced with a particular pathway , ICP use brings additional beneficial effects in directing professional practice in the desired direction . 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories . 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established . 10 Depending on their purpose , the benefits of ICPs may be greater for certain patient subgroups than others . 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits . 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice , particularly in circumstances in which ICP use is a significant change in organisational culture . 13 ICP documentation can introduce scope for new kinds of error . Conclusions ICPs are most effective in context s where patient care trajectories are predictable . Their value in setting s in which recovery pathways are more variable is less clear . ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services ; their value in context s where inter-professional working is well established is less certain . None of the studies review ed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation Background Mobile health apps have emerged as supportive tools in the management of advanced cancers . However , only a few apps have self-monitoring features , and they are not st and ardized and vali date d. Objective This study aim ed to develop and vali date a multidisciplinary mobile care system with self-monitoring features that can be useful for patients with advanced gastrointestinal cancer . Methods The development of the multidisciplinary mobile health management system was divided into 3 steps . First , the service scope was set up , and the measurement tools were st and ardized . Second , the service flow of the mobile care system was organized . Third , the mobile app ( Life Manager ) was developed . The app was developed to achieve 3 major clinical goals : support for quality of life , nutrition , and rehabilitation . Three main functional themes were developed to achieve clinical goals : a to-do list , health education , and in-app chat . Thirteen clinical ly oriented measures were included : the modified Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events question naire , Scored Patient-Generated Subjective Global Assessment ( PG-SGA ) , distress , European Organization for Research and Treatment of Cancer Quality of Life Question naire , International Physical Activity Question naire – Short Form , Low anterior resection syndrome score , satisfaction rate , etc . To vali date the system , a prospect i ve observational study was conducted . Patients with gastric cancer or colon cancer undergoing chemotherapy were recruited . We followed the subjects for 12 weeks , and selected clinical measures were taken online and offline . Results After the development process , a multidisciplinary app , the Life Manager , was launched . For evaluation , 203 patients were recruited for the study , of whom 101 ( 49.8 % ) had gastric cancer , and 102 ( 50.2 % ) were receiving palliative care . Most patients were in their fifties ( 35.5 % ) , and 128 ( 63.1 % ) were male . Overall , 176 subjects ( 86.7 % ) completed the study . Among subjects who dropped out , the most common reason was the change of patient ’s clinical condition ( 51.9 % ) . During the study period , subjects received multiple health education sessions . For the gastric cancer group , the “ general gastric cancer education ” was most frequently viewed ( 322 times ) , and for the colon cancer group , the “ warming-up exercise  ” was most viewed ( 340 times ) . Of 13 measurements taken from subjects , 9 were taken offline ( response rate : 52.0 % to 90.1 % ) , and 3 were taken online ( response rate : 17.6 % to 57.4 % ) . The overall satisfaction rate among subjects was favorable and ranged from 3.93 ( SD 0.88 ) to 4.01 ( SD 0.87 ) on the 5-point Likert scale . Conclusions A multidisciplinary mobile care system for patients with advanced gastrointestinal cancer was developed with clinical ly oriented measures . A prospect i ve study was performed for its evaluation , which showed favorable satisfaction BACKGROUND The feasibility of conducting a definitive r and omised controlled trial ( RCT ) evaluating the clinical effectiveness and cost-effectiveness of scoliosis-specific exercises ( SSEs ) for adolescent idiopathic scoliosis ( AIS ) is uncertain . OBJECTIVES The aim of this study was to assess the feasibility of conducting a large , multicentre trial of SSE treatment for patients with AIS , in comparison with st and ard care , and to refine elements of the study design . The objectives were to ( 1 ) up date a systematic review of controlled trials evaluating the efficacy of SSE in AIS ; ( 2 ) survey UK orthopaedic surgeons and physiotherapists to determine current practice , patient population s and equipoise ; ( 3 ) r and omise 50 adolescents to a feasibility trial of either usual care or SSE interventions across a range of sites ; ( 4 ) develop , document and assess acceptability and adherence of interventions ; ( 5 ) assess and describe training requirements of physiotherapists ; and ( 6 ) gain user input in all relevant stages of treatment and protocol design . DESIGN Multicomponent feasibility study including UK clinician survey , systematic literature review and a r and omised feasibility trial . SETTING The r and omised feasibility study involved four secondary care NHS trusts providing specialist care for patients with AIS . PARTICIPANTS The r and omised feasibility study recruited people aged 10 - 16 years with mild AIS ( Cobb angle of < 50 ° ) . INTERVENTIONS The r and omised study allocated participants to st and ard practice of advice and education or a physiotherapy SSE programme supported by a home exercise plan . Our choice of intervention was informed by a systematic review of exercise interventions for AIS . MAIN OUTCOME MEASURES The main outcome was feasibility of recruitment to the r and omised study . Other elements were to inform choice of outcomes for a definitive trial and included curve severity , quality of life , requirement for surgery/brace , adverse events , psychological symptoms , costs and health utilities . RESULTS A UK survey of orthopaedic consultants and physiotherapists indicated a wide variation in current provision of exercise therapy through physiotherapy services . It also found that clinicians from at least 15 centres would be willing to have their patients involved in a full study . A systematic review up date found five new studies that were generally of low quality but showed some promise of effectiveness of SSE . The r and omised study recruited 58 patients from four NHS trusts over 11 months and exceeded the pre-specified target recruitment rate of 1.4 participants per centre per month , with acceptable 6-month follow-up ( currently 73 % ) . Adherence to treatment was variable ( 56 % of participants completed treatment offered ) . The qualitative study found the exercise programme to be highly acceptable . We learnt important lessons from patient and public involvement during the study in terms of study and intervention presentation , as well as practical elements such as scheduling of intervention sessions . CONCLUSIONS A definitive RCT evaluating clinical effectiveness and cost-effectiveness of SSE for idiopathic scoliosis is warranted and feasible . Such a RCT is a priority for future work in the area . There is a sufficiently large patient base , combined with willingness to be r and omised within specialist UK centres . Interventions developed during the feasibility study were acceptable to patients , families and physiotherapists and can be given within the affordability envelope of current levels of physiotherapy commissioning . TRIAL REGISTRATION Current Controlled Trials IS RCT N90480705 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 19 , No. 55 . See the NIHR Journals Library website for further project information Rationale Stroke is the leading cause of death and disability in rural China . For stroke patients residing in re source -limited rural areas , secondary prevention and rehabilitation are largely unavailable , and where present , are far below evidence -based st and ards . Aim This study aims to develop and implement a simplified stroke rehabilitation program that utilizes nurses and family caregivers for service delivery , and evaluate its feasibility and effectiveness in rural China . Methods and design This 2-year r and omized controlled trial is being conducted in 2–3 county hospitals located in northwest , northeast , and southwest China . Eligible and consenting stroke in patients ( 200 in total ) have been recruited and r and omized into either a control or intervention group . Nurses in the county hospital are trained by rehabilitation specialists and in turn train the family caregivers in the intervention group . They also provide telephone follow-up care three times post discharge . The recruitment , baseline , intervention , follow-up care , and evaluation are guided by the RECOVER mobile phone app specifically design ed for this study . Study outcome The primary outcome is patients ’ Barthel Index ( activities of daily living : mobility , self-care , and toileting ) at 6 months . Process and economic evaluation will also be conducted . Discussion The results of our study will generate initial high- quality evidence to improve stroke care in re source -scarce setting s. If proven effective , this innovative care delivery model has the potential to improve the health and function of stroke patients  , relieve caregiver burden , guide policy-making , and advance translational research in the field of stroke care Background This systematic review up date d and extended the " UK evidence report " by Bronfort et al. ( Chiropr Osteopath 18:3 , 2010 ) with respect to conditions/ interventions that received an ' inconclusive ’ or ' negative ’ evidence rating or were not covered in the report . Methods A literature search of more than 10 general medical and specialised data bases was conducted in August 2011 and up date d in March 2013 . Systematic review s , primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included . Study quality was assessed using st and ardised instruments , studies were summarised , and the results were compared against the evidence ratings of Bronfort . These were either confirmed , up date d , or new categories not assessed by Bronfort were added . Results 25,539 records were found ; 178 new and additional studies were identified , of which 72 were systematic review s , 96 were r and omised controlled trials , and 10 were non-r and omised primary studies . Most ' inconclusive ’ or ' moderate ’ evidence ratings of the UK evidence report were confirmed . Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases ( manipulation/mobilisation [ with exercise ] for rotator cuff disorder ; spinal mobilisation for cervicogenic headache ; and mobilisation for miscellaneous headache ) . In addition , evidence was identified on a large number of non-musculoskeletal conditions not previously considered ; most of this evidence was rated as inconclusive . Conclusions Overall , there was limited high quality evidence for the effectiveness of manual therapy . Most review ed evidence was of low to moderate quality and inconsistent due to substantial method ological and clinical diversity . Areas requiring further research are highlighted Background If eHealth interventions are not used ( properly ) , their potential benefits can not be fulfilled . User perceptions of eHealth are an important determinant of its successful implementation . This study examined how patients with chronic obstructive pulmonary disease ( COPD ) and their physiotherapists ( PHTs ) value an eHealth self-management intervention following a period of use . Objective The study aim ed to evaluate the perceptions of COPD patients and their PHTs as eHealth users . Methods In this study , an eHealth self-management intervention ( website and mobile phone app ) aim ed at stimulating physical activity ( PA ) in COPD patients was evaluated by its users ( patients and PHTs ) . As participants in a r and omized controlled trial ( RCT ) , they were asked how they valued the eHealth intervention after 6 months ’ use . Interview requests were made to 33 PHTs from 26 participating practice s , and a question naire was sent to 76 patients . The question naire was analyzed in Excel ( Microsoft ) . The interviews with the PHTs and text messages ( short message service , SMS ) sent between patients and PHTs were transcribed and independently coded in MAXQDA 10 for Windows ( VERBI GmbH ) . Results A total of 60 patients with COPD filled out the question naire , and 24 PHTs were interviewed . The mobile phone app was used 89.0 % ( 160.2/180 days ) ( st and ard deviation [ SD ] 18.5 ) of the time by patients ; 53 % ( 13/24 ) of PHTs reported low or no use . Patients scored the ease of use of the app 5.09 ( SD 1.14 ) ( on a 7-point scale ) . They found the presentation of the PA information in the app to be clear , insightful , and stimulating . All PHTs judged the website as explicit and user-friendly but had trouble devising a new PA goal for their patients . Patients mostly sent informative , neutral messages concerning the PA goal , and PHTs sent mostly motivating , positive messages concerning the PA goal . Messages were not perceived as supportive in reaching the PA goal according to the patients . Perceived usefulness of the intervention for the PHTs was the objective measurement of PA , the ability to see PA patterns over time , and the ability to use the intervention as a tool to give their patients insight into their PA . For patients , it was that the intervention supported them in increasing their PA and that it made them feel fitter . Barriers to use of the intervention according to the PHTs were time constraints and financial reasons . Seventy-nine percent ( 19/24 ) of the PHTs and 58 % ( 35/60 ) of the patients mentioned they would be interested in using the intervention in the future . Conclusions PHTs and COPD patients had positive feelings regarding the functionality and potential of the eHealth self-management intervention . This paper addresses a number of topics that may aid in the successful development and implementation of these types of eHealth interventions in the future Introduction : Antipsychotic polypharmacy ( APP ) , the concomitant use of ≥ 2 antipsychotics , is common in clinical practice . Prior review s have focused on the efficacy of APP , but no systematic review exists regarding the safety and tolerability of this practice . Areas covered : A systematic review of adverse effects associated with APP was conducted to prepare this review ; case series with ≥ 2 patients , chart review s , naturalistic , data base , cohort and r and omized studies that reported on the association between APP in general or specific APP combinations and global or specific adverse effect were included . Method ological limitations of available studies are discussed and recommendations for clinicians and future research are provided . Expert opinion : Across mostly small and uncontrolled studies , APP has been associated with increased global side effect burden , rates of Parkinsonian side effects , anticholinergic use , hyperprolactinemia , sexual dysfunction , hypersalivation , sedation/somnolence , cognitive impairment and diabetes . Effects on akathisia and mortality were inconclusive . Although some combinations , particularly aripiprazole augmentation of an agent with greater side effect burden , may reduce weight gain , dyslipidemia , hyperprolactinemia and sexual dysfunction , APP should remain a last-resort treatment option after monotherapy , switching and non-antipsychotic combinations have failed . More data are needed to further inform the individualized risk – benefit evaluation of APP Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.20 None of the studies assessed the balance of costs and benefits of ICP use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . Conclusions Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay . ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter‐professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP‐managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs Community practitioners have usually been slow to adopt advances from clinical trials , and serious deficiencies in the use of these advances can continue for years ( 1 - 3 ) . Because of the urgent need to make major advances in combating HIV and the serious consequences of a slow response to such advances , policymakers , medical leaders , and community activists have strenuously promoted their adoption in community practice . Few clinical trials have received as much widespread publicity and attention as Pediatric AIDS Clinical Trials Group ( PACTG ) Protocol 076 ( 4 ) . This trial result ed in the first major breakthrough in HIV prevention : Vertical transmission of HIV decreased by two thirds when women received zidovudine therapy in the second and third trimester of pregnancy , as well as intrapartum , and their children received a short course of zidovudine after delivery . Because of these dramatic findings , the trial was terminated in February 1994 after its first interim analysis , and the results were announced . Diverse approaches were used to educate patients and providers about PACTG Protocol 076 , including news media ( 5 ) , state and Public Health Service expert panel endorsement and treatment guidelines ( 6 ) , direct mailings to practitioners , and community-based educational efforts that targeted women with or at risk for HIV infection ( 7 ) . Publication of the trial 's findings in November 1994 was met with further efforts to ensure that this preventive intervention would be used in community practice . We sought to evaluate the pace at which prescribed antiretroviral treatment for HIV-infected pregnant women enrolled in the New York State Medicaid program changed after PACTG Protocol 076 and to identify factors of health care delivery associated with early adoption of this new st and ard of care . We expected that women whose providers were under state contract to deliver HIV-focused ambulatory services and coordination of care ( 8 , 9 ) would be more likely to receive antiretroviral therapy because of the beneficial effect of HIV-experienced care on survival ( 10 , 11 ) and on appropriate use of HIV-related treatments ( 12 ) . We also predicted that women who were treated at an institution conducting trials to prevent vertical transmission would be more likely to benefit from the PACTG Protocol 076 advance . More frequent use of prenatal care and receipt of enhanced prenatal services ( 13 ) were predicted to be associated with being prescribed antiretroviral therapy because these two factors indicate increased access to comprehensive prenatal care and more opportunities for providers to initiate treatment . Among women who used illicit drugs , we hypothesized that those receiving methadone treatment would be more likely to receive antiretroviral therapy during pregnancy because of improved access to care ( 14 ) . We also discuss potentially important approaches that can ensure expeditious integration of important clinical breakthroughs into community practice . Methods Study Sample On the basis of physician review , we up date d a tested method of identifying HIV-infected women [ 15 ] to account for changes in coding of HIV infection , treatments , and services . The review encompassed more than 1000 r and omly selected clinical and treatment histories of women who were enrolled in the New York State Medicaid program ; had delivered children from 1993 through 1994 ; and had at least one International Classification of Diseases , Ninth Revision , Clinical Modification diagnosis , treatment , or service code that suggested HIV disease . The revised HIV case finding required 1 ) one inpatient or two outpatient diagnoses of HIV seropositivity or infection , 2 ) one outpatient diagnosis of HIV seropositivity or infection with one HIV care rate code , 3 ) an AIDS-defining diagnosis , or 4 ) receipt of antiretroviral therapy . We created a file on cl aims and eligibility longitudinal data for women who were enrolled in the New York State Medicaid program , were identified as HIV-infected , and had one or more deliveries ( total deliveries , n=3037 ) from January 1993 through September 1996 . The files included data from 3 years before and 1 year after each woman 's last delivery and were stripped of patient identifiers for analysis . For women who had multiple deliveries in the study years , we selected the last delivery for analysis ; thus , 261 deliveries were eliminated . We then linked vital statistics birth certificates for 2655 of 2776 deliveries ( 95 % ) by using Social Security number , date of admission for delivery , site of delivery , child 's date of birth , and father 's name . Vital statistics records offered demographic data , education , parity , gestational age at delivery , birth weight , and self-reported substance use during pregnancy . Cl aims provided information on diagnoses ( up to five per inpatient cl aim and two per outpatient cl aim ) , procedures , payment rates , and filled prescriptions . Because key data were missing or sample size was small , we excluded the few persons who lacked data on ethnicity ( n=32 ) or were Asian or Native American ( n=16 ) . Outcome Measures We identified pharmacy cl aims during the study period for all antiretroviral drugs approved by the Food and Drug Administration . Gestational age at delivery was usually determined from physician estimate or , when this estimate was unavailable ( 3.3 % of persons ) , from the mother 's estimate of the date of her last menstrual cycle . From these data , we determined prescribed antiretroviral therapy during the second or third trimester . Maternal and Health Care Measures We did not have access to the results of laboratory tests , such as data on viral load or CD4 cell count . To evaluate maternal HIV disease stage , we identified diagnoses that strongly predicted mother-to-child HIV transmission ( 16 ) . The three clinical groups of HIV status were the following : severe ( one or more AIDS-defining conditions , such as Pneumocystis carinii pneumonia , before or<1 year after delivery ) , moderate ( bacterial or unspecified pneumonia or anemia during pregnancy ) , and mild ( no moderate or severe conditions ) . Chronic medical conditions , including hypertension , asthma , and diabetes , were identified from cl aims made during , before , and after pregnancy . We determined use of illicit drugs by applying a tested approach to the cl aims [ 17 ] . This approach search ed for methadone maintenance service codes , medically supervised nondrug treatment service codes , or diagnoses for illicit drug use . Self-reported illicit drug use was also identified from vital statistics . Pregnant women were divided into four categories of drug use : 1 ) use of regulated methadone  , 2 ) current use of illicit drugs , 3 ) history of use of illicit drugs , and 4 ) no evidence of use of illicit drugs . Smoking and drinking during pregnancy were determined from self-reported vital statistics . We assessed the adequacy of the timing and number of prenatal care visits by using Kotelchuck 's Adequacy of Prenatal Care Utilization ( APNCU ) measures ( 18 ) and by following a previously reported approach ( 19 ) . We applied the APNCU measures to visits to primary care physicians , obstetricians or gynecologists , or HIV-specific physicians or clinics ( that is , physicians or clinics specializing in infectious disease , allergy or immunology , oncology , or HIV-focused care ) . The APNCU categories of intermediate care ( 50 % to 79 % of expected visits ) and adequate care ( 80 % to 109 % of expected visits ) were grouped together , as recommended ( 20 ) . The APNCU category of adequate-plus care ( 110 % of expected visits ) was also included with the adequate care group because prescribed antiretroviral therapy was similarly expected to be greater . To determine receipt of services from providers who were likely to have greater expertise in HIV care , we examined receipt of HIV-focused services and provider specialty . We identified any visit to any provider who was under contract to New York State to offer many HIV-specific services and to coordinate care in exchange for increased Medicaid payment ( 8 , 9 ) . We also created a variable for at least one visit to a provider in an HIV-related specialty ( infectious disease , hematology , oncology , or allergy and immunology ) . We then created dummy variables for the four combinations of these variables . Because only nine women received HIV-focused services but no specialty care  , we grouped these women with those who received both , leaving three dummy variables . We also flagged women who had one or more visits to centers that participated in any federally sponsored trials of antiretroviral therapy for prevention of mother-to-child transmission . Finally , we identified any visit to a provider in the Prenatal Care Assistance Program who was under contract to the state to deliver many prenatal services , such as case management , health education , assessment or prevention of adverse outcomes , and nutritional services , to Medicaid enrollees ( 13 ) . Statistical Analysis We determined the proportion of women delivering in each study month who were prescribed  antiretroviral therapy . Nonparametric ( lowess ) smoothed averages over calendar time were plotted . We divided our analysis into three time periods : period 1January 1993 through February 1994 ( the month when the trial results were announced ) , period 2March 1994 through November 1994 ( the month when the trial results were published ) , and period 3December 1994 through September 1996 . We used the chi-square test to examine bivariate associations of maternal demographic , clinical , and health care characteristics with receipt of  antiretroviral therapy during pregnancy . Age was grouped into five categories . For each time period , a series of multivariable logistic regression models were estimated to determine the independent effects of maternal and health care variables on outcome . We first fit a baseline multivariate model including only maternal variables in any of the time periods that were bivariately associated with outcome ( P<0.2 ) . To examine the BACKGROUND AND PURPOSE Physiotherapists ' use of research evidence with clinical decision-making has interested research ers world-wide since 1980 ; however , little is known about such practice s in Australia . The present survey sought information on Australian physiotherapists ' perceptions of the importance of research , and barriers to uptake of evidence in clinical practice , when compared with an international cohort from 2001 . METHOD An Australian-relevant version of an English ( UK ) National Health Service ( NHS ) survey instrument was used to canvass 453 physiotherapists , r and omly selected from the South Australian Physiotherapy Registration Board 2004 - 2005 records . The first survey was mailed in August 2005 , a reminder was sent two weeks later to non-responders and a follow-up survey was sent in April 2006 to non-responders whose addresses had changed since 2005 . RESULTS There was a 51 % response rate . Of the non-responders , 12 % were not contactable at their listed address , highlighting the mobility of Australian physiotherapists . Most respondents had undertaken research as students ( 59.5 % ) or as students and clinicians ( 11.5 % ) . Of these , 37.1 % were encouraged to embark on more research , and 20.5 % were discouraged . The significant predictors of positive perceived importance of research were : previous research experience ; being positive about undertaking further research ; working in hospitals and holding a postgraduate degree . Clinicians working privately were significantly less likely than managers to be positive about research importance . The only significant predictor for not perceiving barriers to uptake of evidence was being positive about undertaking future research . CONCLUSIONS The study identified constraints on uptake of evidence into practice that were related to accessing , reading and interpreting published research , and implementing findings . Found consistently across employment categories were barriers relating to lack of time , uncertainty about what the research reported , scepticism about the value of research and being isolated from peer support and literature sources . The responses indicated a positive shift towards evidence uptake since the 2001 NHS survey , suggesting an influence of increased exposure to information on evidence -based practice . A greater focus on research whilst training , the application of educational strategies for empowerment , better knowledge transfer and upskilling within the workplace , and ensuring dedicated time and organizational support for research activities are indicated Prediction relates to estimating the probability of something currently unknown . In the context of medical research , prediction typically concerns either diagnosis ( probability of a certain condition being present but not yet detected ) or prognosis ( probability of an outcome developing in the future ) ( 13 ) . Prognosis applies not only to sick persons or those with an established diagnosis but also to , for example , pregnant women at risk for diabetes ( 4 ) . Prediction research includes predictor finding studies , prediction model studies ( development , validation , and extending or updating ) , and prediction model impact studies ( 1 ) . Predictor finding studies ( also known as risk factor or prognostic factor studies ) aim to identify which predictors ( such as age , disease stage , or biomarkers ) independently contribute to the prediction of a diagnostic or prognostic outcome ( 1 , 5 ) . Prediction model studies aim to develop , vali date , or up date ( for example , extend ) a multivariable prediction model . A prediction model uses multiple predictors in combination to estimate probabilities to inform and often guide individual care ( 2 , 6 , 7 ) . These models can predict an individual 's probability of either currently having a particular outcome or disease ( diagnostic prediction model ) or having a particular outcome in the future ( prognostic prediction model ) . Both types of model are widely used in various medical domains and setting s ( 810 ) , as evidence d by the large number of models developed in cancer ( 11 , 12 ) , neurology ( 13 , 14 ) , and cardiovascular disease ( 15 ) . Prediction models are sometimes described as  risk prediction models , predictive models , prediction indices or rules , or risk scores ( 2 , 7 ) . An example is QRISK2 for predicting cardiovascular risk ( 16 ) . Prediction model impact studies evaluate the effect of using a model to guide patient care compared with not using such a model . They use a comparative design , such as a r and omized trial , to study the model 's effect on clinical decision making , patient outcomes , or costs of care ( 1 ) . Systematic review s have a key role in evidence -based medicine and the development of clinical guidelines ( 1719 ) . They are considered to provide the most reliable form of evidence for the effects of an intervention or diagnostic test ( 20 , 21 ) . Systematic review s of prediction models are a relatively new and evolving area but are increasingly undertaken to systematic ally identify , appraise , and summarize evidence on the performance of prediction models ( 1 , 6 , 22 ) . Assessing the quality of included studies is a crucial step in any systematic review ( 20 , 21 ) . The QUIPS ( Quality In Prognosis Studies ) tool has been developed to assess risk of bias ( ROB ) in predictor finding ( prognostic factor ) studies ( 23 ) . Research ers can use the revised Cochrane ROB Tool ( ROB 2.0 ) ( 24 ) to investigate the method ological quality of prediction model impact studies that use a r and omized comparative design , or ROBINS-I ( Risk Of Bias In Nonr and omized Studies of Interventions ) for those that use a nonr and omized comparative design ( 25 ) . As more prediction model studies and systematic review s of such studies are used as evidence for clinical guidance , a tool facilitating quality assessment for individual prediction model studies is urgently needed . We present PROBAST ( Prediction model Risk Of Bias ASsessment Tool ) , a tool to assess the ROB and concerns regarding the applicability of diagnostic and prognostic prediction model studies . PROBAST can be used to assess studies of model development and model validation , including those updating a prediction model ( Box 1 [ 26 ] ) . We refer to the accompanying explanation and elaboration document ( 27 ) , for detailed explanations of how to use PROBAST and how to judge ROB and applicability . Box 1 . Types of diagnostic and prognostic modeling studies or reports addressed by PROBAST . Adopted from the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) and CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) guidance ( 7 , 26 ) . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Methods : Development of PROBAST Development of PROBAST was based on a 4-stage approach for developing health research reporting guidelines : define the scope , review the evidence base , use a Web-based Delphi procedure , and refine the tool through piloting ( 28 ) . Guidelines explicitly aim ed at the development of quality assessment tools were not available at the time ( 29 ) . Development Stage 1 : Scope and Definitions A steering group of 9 experts in prediction model studies and development of quality assessment tools agreed on key features of the desired scope of PROBAST . A panel of 38 experts with different background s further refined the scope during the Web-based Delphi procedure . PROBAST was design ed mainly to assess primary studies included in a systematic review . The group agreed that PROBAST would assess both risk of bias and concerns regarding applicability of a study evaluating a multivariable prediction model to be used for individualized diagnosis or prognosis . A domain-based structure was adopted , similar to that used in other ROB tools , such as ROB 2.0 ( 24 ) , ROBINS-I ( 25 ) , QUADAS-2 ( Quality Assessment of Diagnostic Accuracy Studies 2 ) ( 30 ) , and ROBIS ( 31 ) . We agreed that PROBAST should cover primary studies that develop , vali date , or up date multivariable prediction models aim ing to make individualized predictions of a diagnostic or prognostic outcome ( Box 1 ) . Studies that use multivariable modeling techniques to identify predictors ( such as risk or prognostic factors ) associated with an outcome but do not attempt to develop , vali date , or up date a model for making individualized predictions are not covered by PROBAST ( 5 ) . Therefore , PROBAST is not intended for predictor finding studies or prediction model impact studies . Studies of diagnostic and prognostic models often use different terms for predictors and outcomes ( Box 2 ) . A multivariable prediction model is defined as any combination or equation of 2 or more predictors for estimating probability or risk for an individual ( 6 , 7 , 3234 ) . Box 2 . Differences between diagnostic and prognostic prediction model studies . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Development Stage 2 : Review of Evidence We used the following 3 approaches to build an evidence base to inform the development of PROBAST : identifying relevant method ological review s in the area of prediction model research ( November 2012 to January 2013 ) , asking members of the steering group to identify relevant method ological studies ( January 2013 to March 2013 ) , and using the Delphi procedure to ask members of the wider group to identify additional evidence ( February 2012 to July 2014 ) . Identified literature was used to guide the scope and produce an initial list of signaling questions to consider for inclusion in PROBAST ( 1 , 2 , 57 , 26 , 3340 ) . We grouped signaling questions into common themes to identify possible domains . Additional literature provided as part of the Web-based surveys informed development of the explanation and elaboration document . Development Stage 3 : Web-Based Delphi Procedure We used a modified Delphi process to gain feedback and agreement on the scope , structure , and content of PROBAST . Web-based surveys were developed to gather structured feedback for each round . The 38-member Delphi group comprised method ological experts in prediction model research and development of quality assessment tools , experienced systematic review ers , commissioners , and representatives of reimbursement agencies . We included various stakeholders to ensure that the views of end users , method ological experts , and decision makers were represented . The Delphi process consisted of 7 rounds . Round 1 asked about the scope of the tool , and participants agreed to focus on prediction model studies and follow a domain-based structure . Round 2 aim ed to identify relevant domains and agree on which to include . The signaling questions for domains were refined in rounds 3 to 5 . Respondents used a 1-to-5 Likert scale to rate each proposed signaling question for inclusion . They could also suggest rephrasing , provide supporting evidence ( such as references to relevant studies ) , and suggest missing signaling questions . Round 6 refined the domains and introduced further optional guidance for using PROBAST . In the last round , participants received the agreed draft version of PROBAST and had the opportunity to provide any final feedback . Development Stage 4 : Piloting and Refining the Tool We held 6 workshops on PROBAST at consecutive annual Cochrane Colloquia ( Quebec , Canada , 2013 ; Hyderabad , India , 2014 ; Vienna , Austria , 2015 ; Seoul , South Korea , 2016 ; Cape Town , South Africa , 2017 ; and Edinburgh , United Kingdom , 2018 ) . We also held numerous consecutive workshops with MSc and PhD students ( for example , the master 's program in epidemiology at Utrecht University [ Utrecht , the Netherl and s ] and the Evidence -Based Health Care program at Oxford University [ Oxford , United Kingdom ] ) . In these workshops , we piloted the then-current version of PROBAST to gather feedback on practical issues associated with using the tool so that we could further refine and subsequently vali date it . Finally , more than 50 review groups have already piloted PROBAST versions , including the final version , in their review s. Topics included cancer , cardiology , endocrinology , pulmonology , and orthopedics . All feedback received from these initiatives was used to further inform the content and structure of PROBAST , wording of the signaling questions , and content of the guidance documents ( 27 ) . Results : The PROBAST Tool What Does PROBAST Assess ? PROBAST assesses both risk of bias and concerns regarding applicability of primary studies that developed or vali date d multivariable prediction models for diagnosis or prognosis ( Boxes 1 and 2 )
The quality of the PROMs varied greatly , with Satisfaction most commonly measured utilizing non-st and ardized locally-devised tools ; the EuroQol five-dimensions question naire ( EuroQoL-5D ) and 36-Item Short-Form ( SF-36 ) cited most frequently to capture QoL ; and the Visual Analogue Scale ( VAS ) to capture Pain .
APPs utilized a multiplicity of PROMs across a range of MSK disorders .
OBJECTIVE Advanced practice physiotherapists ( APPs ) , also known as extended scope physiotherapists , provide a new model of service delivery for musculoskeletal ( MSK ) disorders .
Research to date has largely focused on health service efficiencies , with less emphasis on patient outcomes .
The present systematic review aim ed to identify the  patient-reported outcome measures ( PROMs ) being utilized by APPs .