TeleEducation for Implementing a Clinical Practice Guideline For Amputees

Study Overview
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Brief Summary
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The publication of a Clinical Practice Guideline (CPG) is often not enough for its correct use in the field of health care. There are barriers to the implementation of the CPG recommendations, including those related to the lack of knowledge or skills on the part of health service providers. Strategies have been proposed to improve the implementation of the CPGs through interventions with different levels of effectiveness, such as the use of reminders, informative meetings, sending educational material, audits, among others. Some of these interventions can be carried out through Telehealth strategies, that is, with remote services. The purpose of this study is to evaluate the effectiveness of a Telehealth program to improve the implementation of the Clinical Practice Guideline for diagnosis and preoperative, intraoperative and postoperative treatment of the amputee, the prescription of the prosthesis and comprehensive rehabilitation, through strategies to publicize the recommendations included in the CPG and train doctors, reducing the barriers related to the lack of knowledge of the CPG. For this, two groups of institutions that provide health services in Antioquia will be compared, randomized according to two interventions: the socialization of the recommendations of the CPG for amputees, against a combined strategy of education through a Telehealth platform and the delivery of educational material. Compliance with prioritized recommendations of the CPG will be evaluated, related to surgical techniques, perioperative practices, the prescription of prosthetic components and referral to services that allow the comprehensive rehabilitation of the person with amputation. Additionally, the theoretical knowledge of the doctors of each participating institution before and after the interventions will be evaluated through a written test.

Detailed Description
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The effectiveness of the educational program based on telehealth tools (TeleEducation: virtual course with recommendations from the CPG of lower limb amputees, at least four modules: Orthopedics, surgery, rehabilitation and prostheses; TeleAssistance: virtual conference between CPG researchers and professional from selected hospitals and delivery of educational material containing the recommendations of the CPG) compared to the usual socialization of the CPG in an informative meeting to the health personnel of the institutions, will be evaluated by means of a generalized estimated equation model (GEE) for dichotomous variables using the binomial distribution and logit as a link function since the outcomes that will be used will be handled with two coded response options 1 = satisfy 0 = does not satisfy and given the design of conglomerates where the measurements would be correlated. The investigators are expecting to improve the implementation of the CPG be at least 15% higher than compare the intervention group with the control group. The effectiveness of a telehealth based strategy is expected to improve the Implementation of the Clinical Practice Guide for diagnosis and preoperative treatment, intraoperative and postoperative period of the amputated person, the prescription of the prosthesis and the comprehensive rehabilitation in health institutions in Antioquia, Colombia, be at least 15% higher than compare the intervention group with the control group.

Official Title
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Effectiveness of a Telehealth-based Strategy to Improve the Implementation of the Clinical Practice Guide for Lower Limb Amputees by Neurovascular Disease and Trauma: Intervention Trial Randomised by Clusters

Conditions
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Clinical Practice Guidelines, Lower Limb Amputation Above Knee (Injury), Lower Limb Amputation Below Knee (Injury), Lower Limb Amputation Knee, Lower Limb Ischemia, Diabetes Mellitus, Rehabilitation, Prosthesis User

Intervention / Treatment
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* Behavioral: Telehealth-based strategy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Hospital providing medium and high complexity services in Antioquia that are linked or linked to the telehealth network of the University of Antioquia. Patients with lower limb amputation due to traumatic, vascular or diabetes mellitus that are treated in the aforementioned institutions. Health professionals who use CPG for people with amputation. Hospitals, patients and professionals who agree to participate in the project Exclusion Criteria: Patients who were amputated for other causes not included in the target population of the CPG, such as cancer and congenital. Amputee patients under 16 years.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Community based intervention study randomized by clusters. These studies are differentiated by the method of randomisation, in which a group of individuals is randomly assigned to an intervention as a group or cluster rather than as individuals.
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Usual Implementation of the Clinical Practice Guideline<br>In this group, all participants (cluster) have access to the clinical practice guideline that has been sent to the office responsible for implementing the guideline in the hospital. Due to the characteristics of the intervention in the control group it does not work as a placebo or a sham intervention. | Behavioral: Telehealth-based strategy<br>* Teleducation course, based on the CPG recommendations<br>|
| Active Comparator: Tele-education strategy<br>Tele-educational program consisting of a virtual course with recommendations from the CPG of lower limb amputees, with three modules: Perioperative, rehabilitation and prostheses | Behavioral: Telehealth-based strategy<br>* Teleducation course, based on the CPG recommendations<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of patients who received two stages amputation in severe infection | First stage for infection control and second stage for remodeling and definitive closure of the stump | 1 week | 
| Rate of patients who received perioperative analgesia | Perioperative epidural analgesia in patients who are going to be amputated from lower limbs to decrease acute pain of the stump and phantom limb in the period | 72 hours | 
| Rate of patients who received prophylactic antibiotics | Antibiotic use (Cefazolin or Vancomycin in case of allergy to beta-lactams) from 2 hours before the incision until 24 hours after the amputation | 2 hours before the incision until 24 hours after the amputation | 
| Rate of patients who received transfemoral amputation instead of knee disarticulation | Transfemoral amputation instead of knee disarticulation | 24 hours | 
| Rate of patients who received myodesis | Myodesis (Suture of the adductor muscles to the bone through transosseous tunnels) | 24 hours | 
| Rate of patients who received immediate postoperative prosthesis | verify the order of the immediate prosthesis and if it was manufactured | 24 hours | 
| Rate of patients who received a SACH foot | Adapt a solid ankle cushion heel (SACH) foot for amputations of the lower limbs above or below the knee and a low expected level of activity (K1 or K2) | 3 to 6 months | 
| Rate of patients who received an articulated foot | adapt an articulated foot or a dynamic response foot in people with greater activity requirements (K3 / K4) or who must use the prosthesis on irregular or inclined surfaces | 3 to 6 months | 
| Rate of patients who received a prosthetic knee for above knee amputees | Monocentric knee with manual locking or a knee with load brake in the K1 and monocentric or polycentric knee of fluid control in the K2, K3, K4 was prescribed | 3 to 6 months | 
| Rate of patients who received a prosthetic knee for knee disarticulated amputees | mechanical polycentric knee was prescribed for disarticulation in K1 and polycentric fluid control for K2, K3, K4 | 3 to 6 months | 
| Rate of patients who received occupational therapy | occupational rehabilitation and ergonomic adaptations | 3 to 6 months | 
| Rate of patients who received comprehensive Rehabilitation | recommends the implementation of a comprehensive rehabilitation process: cardiopulmonary, musculoskeletal, psychosocial, activities of daily living and work | 2 weeks to 12 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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lower limb amputation, clinical practice guidelines, implementation strategies, rehabilitation