Anna R. Gagliardi

How can we improve guideline use? A conceptual framework of implementability

BackgroundGuidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines.MethodsA guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team.ResultsThe final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic.ConclusionsNumerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

Examining the potential relationship between multidisciplinary cancer care and patient survival: An international literature review

The aim of this review is to examine the relationship between multidisciplinary cancer care and patient survival.

Paucity of qualitative research in general medical and health services and policy research journals: analysis of publication rates

BackgroundQualitative research has the potential to inform and improve health care decisions but a study based on one year of publications suggests that it is not published in prominent health care journals. A more detailed, longitudinal analysis of its availability is needed. The purpose of this study was to identify, count and compare the number of qualitative and non-qualitative research studies published in high impact health care journals, and explore trends in these data over the last decade.MethodsA bibliometric approach was used to identify and quantify qualitative articles published in 20 top general medical and health services and policy research journals from 1999 to 2008. Eligible journals were selected based on performance in four different ranking systems reported in the 2008 ISI Journal Citation Reports. Qualitative and non-qualitative research published in these journals were identified by searching MEDLINE, and validated by hand-searching tables of contents for four journals.ResultsThe total number of qualitative research articles published during 1999 to 2008 in ten general medical journals ranged from 0 to 41, and in ten health services and policy research journals from 0 to 39. Over this period the percentage of empirical research articles that were qualitative ranged from 0% to 0.6% for the general medical journals, and 0% to 6.4% for the health services and policy research journals.ConclusionsThis analysis suggests that qualitative research it is rarely published in high impact general medical and health services and policy research journals. The factors that contribute to this persistent marginalization need to be better understood.

Use of referral reply letters for continuing medical education: A review

Introduction: Referrals between generalists and specialists are a central component of the health care system and necessitate effective communication between the involved providers. Despite the high prevalence of patient referrals and their crucial role in continuity and quality of care, the medical literature demonstrates that generalists may receive little or no information about the care their patients received and little information about the appropriateness of the referral or recommendations for follow‐up care. General practitioners (GPs) prefer teaching that is directly related to their clinical work rather than traditional continuing education such as formal lectures. The purpose of this review is to assess the role of referral reply letters in the continuing education of GPs. Methods: A comprehensive literature search was conducted to November 2001 using MEDLINE, EMBASE, the Cochrane Library, and the Research and Development Resource Base developed by Continuing Education, Faculty of Medicine, University of Toronto, to identify studies that examined the use of referral letters for the transfer of information from specialists to referring physicians. Data on methodology, unit of analysis, main outcome measures, and results were extracted. Results: Of 1,250 articles retrieved, 9 met the eligibility criteria. Three of these analyzed the content of referral reply letters and 6 described the results of surveys of general and specialty physicians. Discussion: Little educational content is currently included in letters from specialists to referring GPs. GPs are receptive to the use of referral replies US sources of learning.

Patient decision aids for cancer treatment: are there any alternatives?

Although patient decision aids (pDAs) are effective, widespread use of pDAs for cancer treatment has not been achieved. The objectives of this study were to perform a systematic review to identify alternate types of decision support interventions (DSIs) for cancer treatment and a meta‐analysis to compare the effectiveness of these DSIs to pDAs.

Beyond the False Negative Rate: Development of Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer

BackgroundSentinel lymph node biopsy (SNLB) has been adopted as the standard method of axillary staging for women with clinically node-negative early-stage breast cancer. The false negative rate as a quality indicator is impractical given the need for a completion axillary dissection to calculate. The objective of this study was to develop practical quality indicators for SLNB using an expert consensus method and to determine if they were feasible to measure.Materials and MethodsWe used a modified Delphi consensus process to develop quality indicators for SLNB. A multidisciplinary expert panel reviewed potential indicators extracted from the medical literature to select quality indicators that were relevant and measurable. Feasibility was determined by abstracting the quality indicator variables from a retrospective chart review.ResultsThe expert panel prioritized 11 quality indicators as benchmarks for assessing the quality of surgical care in SNLB. Nine of the indicators were measurable at the chart or institutional level.ConclusionsA systematic evidence- and consensus-based approach was used to develop measurable quality indicators that could be used by practicing surgeons and administrators to evaluate performance of SLNB in breast cancer.

Exploratory evaluation of surgical skills mentorship program design and outcomes.

Introduction: There are few opportunities for mentorship of practicing surgeons and no evidence to guide the design of such programs. This study explored outcomes and barriers associated with the design of surgical mentorship programs. Methods: Interviews were held with organizers, mentors, and protégés of 2 programs. Data from 23 participant interviews and 23 nonparticipant surveys were analyzed thematically. Results: Participation was greater in the program where planning was participatory and mentors visited protégés. Scheduling was a key barrier, and existing relationships enabled mentorship. Most nonparticipants said they were already trained or had no interest in the skill. Mentorship was valued for exchange of tacit knowledge, hands‐on learning, and real‐time feedback. Mentorship prompted participants to realize gaps in skill; several said they already adopted the new skill, and many were interested in ongoing mentorship. Discussion: Several beneficial outcomes appear to be associated with mentorship, but longitudinal evaluation is required. Telementoring and train‐the‐trainer models may promote participation in surgical mentorship. Participants suggested that technical training be integrated within pre‐ and postmentorship education and follow‐up. Such programs can only be implemented if issues of sponsorship and funding are addressed.

Protocol: developing a conceptual framework of patient mediated knowledge translation, systematic review using a realist approach

BackgroundPatient involvement in healthcare represents the means by which to achieve a healthcare system that is responsive to patient needs and values. Characterization and evaluation of strategies for involving patients in their healthcare may benefit from a knowledge translation (KT) approach. The purpose of this knowledge synthesis is to develop a conceptual framework for patient-mediated KT interventions.MethodsA preliminary conceptual framework for patient-mediated KT interventions was compiled to describe intended purpose, recipients, delivery context, intervention, and outcomes. A realist review will be conducted in consultation with stakeholders from the arthritis and cancer fields to explore how these interventions work, for whom, and in what contexts. To identify patient-mediated KT interventions in these fields, we will search MEDLINE, the Cochrane Library, and EMBASE from 1995 to 2010; scan references of all eligible studies; and examine five years of tables of contents for journals likely to publish quantitative or qualitative studies that focus on developing, implementing, or evaluating patient-mediated KT interventions. Screening and data collection will be performed independently by two individuals.ConclusionsThe conceptual framework of patient-mediated KT options and outcomes could be used by healthcare providers, managers, educationalists, patient advocates, and policy makers to guide program planning, service delivery, and quality improvement and by us and other researchers to evaluate existing interventions or develop new interventions. By raising awareness of options for involving patients in improving their own care, outcomes based on using a KT approach may lead to greater patient-centred care delivery and improved healthcare outcomes.

Self-Directed Learning Needs, Patterns, and Outcomes among General Surgeons.

Introduction: To explore the relationship between self‐directed learning (SDL) needs, patterns, barriers, and outcomes among nonacademic general surgeons. Methods: Participants dictated details of SDL episodes associated with cancer patient management from October 2007 to March 2008. Transcripts were coded thematically. Frequencies were calculated for elements of each SDL stage. Statistical significance among subgroups was established with the use of the Pearson chi‐square test, adjusted for clustering by surgeon. Participants were interviewed by telephone, and transcripts were analyzed by qualitative methods. Results: Of 21 consenting surgeons, 15 submitted 115 cases, and 108 were analyzed. Most involved breast (40.7%), colon (18.5%), or rectal cancer (13.0%); 2 or more clinical tasks (41.7%); and 2 or more questions (89.8%). Information was sought from the Internet (48.1%), colleagues (24.2%), or both (6.8%). Information was partially, or not relevant for 21.3% of cases. Evidence was new for 66.7%, and confirmed knowledge for 10.7% of cases. Learning helped surgeons formulate new (34.2%), or confirm original (16.5%) management plans, or determine that referral was appropriate (39.2%). Use of codified sources was associated with information retrieval (P < .05), and identifying new evidence leading to a change in management from that initially proposed (P ≤ .001). Discussion: Numerous individual and systemic barriers may prevent practicing physicians from undertaking SDL, but provision of structured guidance prompted SDL and resulted in several beneficial outcomes. Further research is needed to validate these findings, and investigate who should support SDL, and how.

Using patient and physician perspectives to develop a shared decision-making framework for colorectal cancer

BackgroundColorectal cancer is the third leading cause of death from cancer worldwide with over 900,000 diagnoses and 639,000 deaths each year. Although shared decision making is broadly advocated as a mechanism by which to achieve patient-centred care, there has been little investigation of patient and physician shared decision-making preferences and practices or the outcomes associated with shared decision making in the context of colorectal cancer.AimThe aim of this study is to determine patient and physician attitudes towards the use of shared decision making in the setting of colorectal cancer.MethodsStandard principles of qualitative research will be used to sample and interview 20 colorectal cancer patients in each of three tertiary care hospitals (n = 60) and 15 surgeons, radiation oncologists, and medical oncologists (n = 45) affiliated with cancer centres. The interview questions will be guided by a conceptual framework defining patient and physician factors that influence the shared decision-making process and associated outcomes in the setting of colorectal cancer. An inductive, grounded approach will be used by two investigators to independently analyze the interview transcripts. These investigators will meet to compare and achieve consensus on themes that will be tabulated to compare barriers, enablers, and outcomes of shared decision making by patient, physician, and contextual factors.DiscussionThis study is the first to examine both patient and physician perspectives on the use of shared decision making for colorectal cancer in North America or elsewhere. It will provide a framework that can be used to describe the shared decision-making process and its outcomes, and evaluate strategies to facilitate this process for patients with colorectal cancer.