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This is a systematic review aimed at evaluating current evidence for short stay endovascular aneurysm repair (EVAR) safety and feasibility. By reducing length of stay through a short stay EVAR pathway, clinicians have the opportunity to reduce patient morbidity and improve cost effectiveness. Objective: Reducing length of stay (LOS) following surgery offers the potential to improve resource utilisation. Endovascular aneurysm repair (EVAR) is now delivered with a low level of morbidity and as such may be deliverable as a "23 hour stay" intervention. This systematic review aims to assess safety, feasibility and cost effectiveness of a short stay EVAR pathway. Methods: A database search of Ovid MEDLINE (1996 e April 2018) and Embase (1974 e April 2018) was completed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. A NewcastleeOttawa Scale was applied to assess study bias. Results: In total, 570 papers were identified through the literature search, of which 32 abstracts were screened. This led to nine papers being assessed for eligibility. From five suitable studies, 450 (75%) patients were successfully discharged the same or next day after EVAR. Complications most often occurred within 3 hours of surgery, and major complications requiring intensive treatment unit admission occurred within 6 hours. Readmission rates were 0e5% for those discharged early, with no difference in 30 day readmission. Early discharge led to a statistically significant cost saving of £13,360 (LOS four days) to £9844 (LOS one day). Conclusion: Selected patients can safely undergo EVAR using a short stay pathway. A period of monitoring 6 h post-operatively for low risk patients would be sufficient. Reducing length of stay after EVAR in the UK from the current median of three days to 1.5 days would free 4361 bed days and lead to a saving of approximately £1,800,000 annually.

Background Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) was a pragmatic, cluster randomized trial assessing the effectiveness of a clinical decision support (CDS) tool in primary care, Nova Scotia, Canada. We evaluated if CDS software versus Usual Care could help primary care providers (PCPs) deliver individualized guideline-based AF patient care. Methods Key study challenges including CDS development and implementation, recruitment, and data integration documented over the trial duration are presented as lessons learned. Results Adequate resources must be allocated for software development, updates and feasibility testing. Development took longer than projected. End-user feedback suggested network access and broadband speeds impeded uptake; they felt further that the CDS was not sufficiently user-friendly or efficient in supporting AF care (i.e., repetitive alerts). Integration across e-platforms is crucial. Intellectual property and other issues prohibited CDS integration within electronic medical records and provincial e-health platforms. Double login and data entry were impediments to participation or reasons for provider withdrawal. Data integration challenges prevented easy and timely data access, analysis, and reporting. Primary care study recruitment is resource intensive. Altogether, 203 PCPs and 1145 of their patients participated, representing 25% of eligible providers and 12% of AF patients in Nova Scotia, respectively. The most effective provider recruitment strategy was in-office, small group lunch-and-learns. PCPs with past research experience or who led patient consent were top recruiters. The study office played a pivotal role in achieving patient recruitment targets. Conclusions A rapid growth in healthcare data is leading to widespread development of CDS. Our experience found practical issues to address for such applications to succeed. Feasibility testing to assess the utility of any healthcare CDS prior to implementation is recommended. Adequate resources are necessary to support successful recruitment for future pragmatic trials. CDS tools that integrate multiple co-morbid guidelines across eHealth platforms should be pursued. Trial registration ClinicalTrials.gov NCT01927367. Registered on August 22, 2013

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Background: Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) was a pragmatic, cluster randomized trial assessing the clinical relevance and effectiveness of a clinical decision support (CDS) tool in the primary care setting of Nova Scotia, Canada. Key challenges encountered included CDS development and implementation (2013-2018), study recruitment (2014-2016) and data analysis (2018 to present). Methods: Clinical and health informatics researchers developed CDS software designed to help primary care providers (PCP) deliver individualized AF patient care based on national guidelines. Features included prioritized automated alerts signaling material changes in patient clinical or biochemical profiles requiring expedited treatment changes. Challenges documented over the trial duration are presented here as lessons learned. Findings: 1) Resources must be allocated for feasibility testing and software development/updates. CDS development took twice as long as projected. Network access and broadband speeds were key impediments to successful uptake. Although modified after pilot testing with an initial cohort of intervention providers, user feedback at study completion suggested the CDS was not sufficiently user-friendly and did not create efficiencies in the clinical management of AF for patients (i.e., repetitive alerts). 2) Integration across e-platforms is crucial. Intellectual property and other technical issues prohibited integration of the CDS within providers’ existing electronic medical records and desired provincial e-health platforms. PCPs cited double data entry/login as impediments to participation/reasons for withdraw. Challenges with data integration across platforms prevented facile and timely data access, analysis and reporting. 3) Study recruitment is resource intensive. In total, 204 PCPs and 1,204 patients participated, representing 25% of all eligible PCPs and 13% of all persons living with AF in Nova Scotia, respectively. The most effective PCP recruitment strategy was in-office, small group lunch and learns. PCPs with past research experience/those who led patient consent processes were top patient recruiters. The study office played a pivotal role in achieving recruitment targets. Conclusions: A rapid growth in healthcare data is leading to the widespread development of CDS software to analyse it. Our experience found practical issues to address if such applications are to succeed. CDS tools that fully integrate multiple critical co-morbid guideline recommendations across eHealth platforms should be pursued. Feasibility testing to assess the practical utility of any healthcare CDS software prior to its implementation is recommended. Lastly, adequate resources are necessary to support successful recruitment of PCPs for future pragmatic clinical trials.