Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, Referrals,

Intervention Description: The article describes the development and implementation of a concussion care pathway, which includes the integration of the Cleveland Clinic Concussion (C3) app to guide clinical decision-making throughout the injury recovery process. The intervention involves the use of the C3 app to provide standardized, biomechanical outcomes that serve as qualifiers to monitor recovery patterns in patients, identify individuals at risk for protracted recovery, and drive referral for specialty services for those not recovering in a timely manner. The C3 app includes assessment modules to measure important aspects of cognitive and motor function, as well as a return to play module to systematically document the six phases of post-injury rehabilitation. The intervention also involves the use of detailed injury documentation to better understand circumstances surrounding concussive injuries with the aim of mitigating risk and improving outcomes. Therefore, the intervention description includes the use of the C3 app for standardized assessment and monitoring of recovery patterns, as well as the documentation of injury details to facilitate understanding and mitigation of risk associated with concussive injuries.

Intervention Results: Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

Conclusion: The article reports statistically significant findings related to the performance of student-athletes on the C3 app modules at baseline and during each post-injury phase of recovery. Specifically, the article reports that Welch's two-sample t-tests revealed a significant difference between student-athletes who recovered within three weeks of injury and those who were still symptomatic three weeks after injury for the following C3 app modules: simple reaction time, choice reaction time, Trail Making Test B, and for two of the six BESS stances quantifying postural sway (double limb stance on foam, tandem stance on foam). These results suggest that athletes who remained symptomatic performed significantly worse on C3 modules measuring information processing, executive function, set switching, and postural stability. However, the article notes that the sensitivity and specificity of these modules with the current data set cannot be determined, as only injured athletes are represented. Therefore, while the article reports statistically significant findings related to the performance of student-athletes on the C3 app modules, the sensitivity and specificity of these modules require further investigation.

Study Design: The study described in the article is a descriptive study that outlines the development and implementation of a concussion care pathway and the integration of technology in the form of a mobile application to enable the care pathway and guide clinical decision-making. The article presents data on the utility of the Cleveland Clinic Concussion (C3) app in facilitating decision-making throughout the injury recovery process, but it does not report on the results of a specific research study. The article describes the process of developing and implementing the concussion care pathway, including the involvement of an interdisciplinary team of experts in concussion care, the use of evidence-based best practices, and the validation and deployment of the C3 app. Therefore, the study design/type is a descriptive study of the development and implementation of a concussion care pathway and the integration of technology to support clinical decision-making.

Setting: The setting for the study described in the article is the Cleveland Clinic. The development and implementation of the concussion care pathway, as well as the validation and deployment of the Cleveland Clinic Concussion (C3) app, were carried out within the Cleveland Clinic enterprise. The interdisciplinary team involved in the development of the care pathway included providers from various departments within the Cleveland Clinic, such as sports medicine, neurology, neurosurgery, rehabilitation medicine, neuroradiology, emergency medicine, primary care, pediatrics, and family medicine, as well as athletic trainers, physical therapists, speech therapists, occupational therapists, nurses, and neuropsychologists. Therefore, the study was conducted within the clinical and research environment of the Cleveland Clinic.

Population of Focus: The target audience for the study described in the article is likely to be healthcare providers involved in the management of concussion, including physicians, athletic trainers, physical therapists, speech therapists, occupational therapists, nurses, and neuropsychologists. The article provides a detailed description of the development and implementation of a concussion care pathway and the integration of technology in the form of a mobile application to enable the care pathway and guide clinical decision-making. The study also presents data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. Therefore, the article is likely to be of interest to healthcare providers who are involved in the care of patients with concussion and who are interested in evidence-based best practices and technology-enhanced approaches to concussion management.

Sample Size: The article does not provide a specific sample size for the study. The study described in the article involves the development and implementation of a concussion care pathway and the validation and deployment of the Cleveland Clinic Concussion (C3) app. The article presents data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process, but it does not provide information on the number of patients or participants involved in the study. Therefore, the sample size for the study is not reported in the article.

Age Range: The age group discussed in the article is primarily focused on student-athletes, as indicated in the representative results section. The study involved 181 student-athletes who were diagnosed with concussion during the 2013-2014 athletic seasons. The age range of the student-athletes is not explicitly mentioned, but it is noted that the mean age of the athletes was 17 years for those who recovered within three weeks of injury and 18 years for those who experienced prolonged recovery. Therefore, the age group of the student-athletes in the study is likely to be in the range of late adolescence to early adulthood.

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, EMR Reminder,

Intervention Description: With assistance from the clinical informatics department, a postpartum-specific note template was created in the electronic health record (EHR) to increased adherence with counseling guidelines recommended by the American College of Obstetrics and Gynecology (ACOG). The template addressed birth spacing, breastfeeding, contraception, depression, and sleep/fatigue, as well as comorbidities requiring follow-up (abnormal Pap smear, gestational diabetes mellitus, and pre-eclampsia). Patients were seen in a resident-run clinic: 100 consecutive visits occurred prior to implementation of the template, while 100 consecutive visits occurred post-implementation with use of the template.

Intervention Results: In visits that occurred without use of the template, counseling was charted as low as 1.0% for birth spacing to as high as 86.0% for contraception. With use of the template, counseling was charted as 100% in all visits for each of the recommended counseling guidelines (all p < 0.001).

Conclusion: A postpartum specific EHR note template shows improvement in adherence with recommended postpartum counseling. We propose that managers in hospitals and clinical practices create OBGYN-specific EHR note templates for clinical use to potentially improve documentation quality. This may increase adherence to documentation of postpartum counseling, with the ultimate goal of increasing adherence to evidence-based counseling guidelines.

Study Design: Retrospective cohort study

Setting: Resident run clinic, Nassau University Medical Center

Population of Focus: Postpartum patients

Sample Size: 200

Age Range: Mean age 30

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Organizational Changes, Hospital Laborist, PROFESSIONAL_CAREGIVER, Consensus Guideline Implementation

Intervention Description: Cesarean delivery is a key performance metric with maternal health implications and significant financial impact. Our hypothesis is that the initiation of a full-time dedicated laborist staff decreases cesarean delivery.

Intervention Results: The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery.

Conclusion: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

Study Design: Retrospective cohort

Setting: 1 tertiary hospital in Nevada

Population of Focus: Nulliparous women who gave birth between October 2006 and October 2011

Data Source: Not specified

Sample Size: Total (n=6,206) Intervention (n=2,654) Modified intervention (n=1,722) Control (n=1,830)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, Note-Taking (caregiver),

Intervention Description: Four core interventions were created for this project. The population health management registry tracked postpartum patients for early postpartum follow‐up. Patients who were 1–3 weeks postpartum were placed on the registry. Two providers (nurse‐midwife and OB/ GYN physician) called patients to ensure they were progressing as expected, with complications referred for either an in‐person office visit or for urgent evaluation in Labor & Delivery or the Emergency Department. The electronic postpartum note template guided review and documentation of ACOG's recommended visit components for postpartum visits. Clinic staff and providers were educated regarding the use of the tools. No incentive was provided for tool use.

Intervention Results: The project aimed to increase the frequency of effective postpartum care visits from 0% to 80% in 8 weeks. The frequency of effective postpartum care visits was 88% by the end of PDSA Cycle 4. The PRATs increased patient postpartum warning sign knowledge, with a project mean risk factor knowledge score of 6 (Goal = 5). The population health registry drove right care by ensuring early postpartum patients were recovering as expected, as seen by a project mean right‐care score of 16 (Goal = 12). The note template increased the effectiveness of postpartum visits, with a mean effective postpartum care score of 10 (Goal = 10).

Conclusion: The Postpartum Readiness and Awareness Tools (PRAT), population health registry, and note template tools improved quality and postpartum care effectiveness over 8 weeks. It is suggested that the PRAT and note template be sustained to increase anticipatory guidance and adherence to postpartum counseling guidelines. It is also recommended that pre‐scheduled telemedicine visits be implemented for early postpartum follow‐ up. Continued tool utilization can increase patient knowledge of postpartum warning signs, early postpartum follow‐up, and comprehensive 6‐week postpartum visits. Further studies are needed to examine the impact of the interventions on clinic‐ specific patient postpartum morbidity and mortality and differ- ences by race.

Study Design: Quality improvement project consisting of four rapid Plan-Do-Study-Act (PDSA) cycles

Setting: Ob/gyn practice in a large academic hospital in the eastern U.S.

Population of Focus: Postpartum patients

Sample Size: 188 patients

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, Quality Improvement, Shortened Appointment Interval

Intervention Description: The addition of a 2-3 week postpartum visit in addition to a 6 week visit, in keeping with guidelines from the American College of Obstetricians and Gynecologists (ACOG. This quality improvement (QI) project was guided by the Quality Implementation Framework, a process model with a systematic and practical approach to implementation. The model has four phases: initial considerations regarding the host setting, creating a structure for implementation, ongoing structure once implementation begins, and improving future applications by learning from experience. The intervention is based on the assumption that adding an earlier prescheduled postpartum appointment would increase the likelihood that women would attend at least one postpartum appointment.

Intervention Results: During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation.

Conclusion: Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings.

Study Design: Quality improvement project consisting of four rapid Plan-Do-Study-Act (PDSA) cycles

Setting: Small nurse practitioner maternity care clinic in an academic health center

Population of Focus: Publlicly-insured women

Sample Size: 25

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Education/Training (caregiver), Screening Tool Implementation, Consensus Guideline Implementation,

Intervention Description: The intervention in this study was the ECHO Autism STAT model, which aimed to provide diagnostic training for primary care providers (PCPs) in screening and diagnosing young children at highest risk for autism. The model included a hybrid approach, combining hands-on training in standardized screening and diagnostic tools with ongoing video-based coaching and mentorship. The program involved monthly videoconferencing sessions where PCPs presented de-identified cases for discussion among the expert team and all participants, received feedback and recommendations, and had access to resources and toolkits for autism and other developmental disorders. Additionally, the program included training on the use of autism-specific screening measures and a diagnostic algorithm for autism, as well as a tiered process for diagnostic evaluation to foster timely access to diagnosis for children with the most severe symptoms,,.

Intervention Results: Results indicated improvements in PCP practice and self-efficacy, and feasibility of the model for enhancing local access to care.

Conclusion: Yes, the study found statistically significant improvements in primary care providers' (PCPs) use of autism-specific screening measures, as well as their self-efficacy in caring for children with autism, from pre- to post-training. Additionally, all participants reported changes in their practice behavior, relationships with patients and families, and perceived positive impact on their communities. However, it is important to note that the study had a small sample size and lacked a control or comparison group.

Study Design: The study design is a pilot project that used the ECHO Autism STAT model to provide diagnostic training for primary care providers (PCPs) based on the Missouri Best Practice Guidelines for diagnosis of ASD. The study used pre- and post-training questionnaires to assess changes in practice behavior and self-efficacy, and de-identified case presentation forms were also examined.

Setting: The study was conducted in underserved areas in the state of Missouri, focusing on training community-based primary care providers (PCPs) to improve screening and diagnosis of young children at highest risk for autism.

Population of Focus: The target audience for the study includes primary care providers (PCPs) such as general pediatricians, family medicine physicians, nurse practitioners, and physician assistants, particularly those practicing in underserved regions of Missouri.

Sample Size: The study initially enrolled a total of 18 primary care providers (PCPs) from 6 distinct geographic regions of the state of Missouri.

Age Range: The age group targeted in the ECHO Autism STAT program is early childhood, specifically focusing on children between the ages of 1 and 60 months. This program aims to improve access to early autism diagnosis and intervention for children in this crucial developmental stage.

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation, HOSPITAL, POPULATION-BASED SYSTEMS, NATIONAL, Policy/Guideline (National), PROFESSIONAL_CAREGIVER, Consensus Guideline Implementation, HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor

Intervention Description: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines.

Intervention Results: Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38-0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46-0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications.

Conclusion: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm.

Study Design: Retrospective cohort

Setting: 1 public university hospital in Pennsylvania

Population of Focus: Nulliparous women who gave birth between September 13, 2013 and February 28, 2014 and between May 1, 2014, to September 28, 2014

Data Source: Not specified

Sample Size: Total (n=567) Pre-intervention (n=275) Post-intervention (n=292)

Age Range: Not Specified