Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.

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Stepped wedge cluster randomised trials: a review of the statistical methodology used and available

Importance Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. Objective To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system. Design, Setting, and Participants Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191 280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42 143) or medical (n = 149 137) if the patient did not receive surgical treatment in the last year of life. Main Outcomes and Measures Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. Results Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P P Conclusions and Relevance In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.

https://jamanetwork.com/journals/jamasurgery/articlepdf/1906152/soi140097.pdf

Use of Palliative Care and Hospice Among Surgical and Medical Specialties in the Veterans Health Administration

Purpose:Advance care planning may ensure care that is concordant with patient wishes. However, advance care plans are frequently absent when needed due to failure to engage patients in planning, in...

http://journals.sagepub.com/doi/pdf/10.1177/1049909117715217

Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review.

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework. This citation analysis commenced from four core articles representing the key stages of the framework’s development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail. The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated. In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

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The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature.

Palliative care and Parkinson's disease: Meeting summary and recommendations for clinical research

Background
Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.

/pdf/intervention-to-improve-care-at-life-s-end-in-inpatient-kbmonhdwuk.pdf

Jessie M. Spencer

Papers

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial