Brigitte Vachon

Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis

BACKGROUND The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA(1c)), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. METHODS We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. FINDINGS We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84,865 patients, and 94 patient randomised controlled trials, including 38,664 patients. In random effects meta-analysis, the QI strategies reduced HbA(1c) by a mean difference of 0·37% (95% CI 0·28-0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05-0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19-4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95-2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA(1c), 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA(1c) control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21-1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01-1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13-1·32), renal function (14 trials; RR 128, 1·13-1·44), and foot abnormalities (22 trials; RR 1·27, 1·16-1·39). However, statin use (ten trials; RR 1·12, 0·99-1·28), hypertension control (18 trials; RR 1·01, 0·96-1·07), and smoking cessation (13 trials; RR 1·13, 0·99-1·29) were not significantly increased. INTERPRETATION Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA(1c) control is poor. FUNDING Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates--Health Solutions).

Discriminative and predictive validity assessment of the Quebec Task Force Classification

Study Design. A prospective cohort study of workers with low back pain who had been absent from work for more than 4 weeks was conducted. Objective. To assess the discriminative and predictive validity of the Quebec Task Force Classification for workers during the subacute phase of disability from back pain. Summary of Background Data. The Quebec Task Force Classification was designed for clinical decision making, prognosis establishment, quality of care evaluation, and scientific research in low back pain. Methods. For this study, 104 workers absent from work because of back pain were classified according to the first four categories of the Quebec Task Force Classification 4 weeks after their first day of work absence. They then were randomized into four treatment groups: standard care (control), clinical–rehabilitation intervention, occupational intervention, and the Sherbrooke model (a combination of the clinical–rehabilitation and occupational interventions). Functional status, pain level, and work status were assessed at baseline and after 1 year. Duration of full compensation and back-related costs were calculated over a mean follow-up period of 6.5 years. The discriminative validity of the Quebec Task Force Classification was evaluated using Kendall tau correlation coefficients. Predictive validity was evaluated using logistic regression analyses. Age, gender, comorbidities, body mass index, and treatment group were considered as potential confounders. Results. Significant but low correlation coefficients were found between Quebec Task Force Classification categories and functional status scores at baseline. Subjects classified as having distal radiating pain (categories 3 and 4) at baseline were more likely to have a lower functional status, higher pain level, and no return to regular work at the 1-year follow-up evaluation. They also were more likely to accumulate more days of full compensation and to cost more after a mean follow-up period of 6.5 years. Conclusion. The Quebec Task Force Classification demonstrated good predictive ability by discriminating between subjects with and those without distal radiating pain.

From evidence to community practice in work rehabilitation: the Quebec experience.

BackgroundThe causes of prolonged disability due to back pain are multiply determined, involving medical, social, and environmental factors. Possible solutions to the problem of prolonged back pain disability have emerged from recent research but few efforts have been made to transfer evidence-based programs to large community settings. ObjectiveThis article describes three phases of the process of transfer of evidence from rehabilitation research to community practice in the province of Quebec. Methods and ResultsPhase A: Based on literature review and expert knowledge, the Sherbrooke model was developed and assessed through a population-based, randomized clinical trial. Results at 1-year follow-up showed quicker return to regular work and improvement of quality of life; the 6-year follow-up showed the cost-effectiveness of the method.Phase B: Based on the Sherbrooke model experience and recent evidence, a new program addressing the disability paradigm was developed and implemented in the province of Quebec (Canada). Results at 1- and 3-year follow-ups showed that only 24% of workers were not working owing to their musculoskeletal disorder. The program is presently being tested through a population-based, randomized clinical trial in a population of construction workers.Phase C: To implement the program at a provincial level, a network for management, research and education in work rehabilitation was developed. An external assessment is presently planned to evaluate return to work and economic outcomes and quality of implementation of the program in various settings.

Engaging primary care practitioners in quality improvement: making explicit the program theory of an interprofessional education intervention.

BackgroundThe scientific literature continues to advocate interprofessional collaboration (IPC) as a key component of primary care. It is recommended that primary care groups be created and configured to meet the healthcare needs of the patient population, as defined by patient demographics and other data analyses related to the health of the population being served. It is further recommended that the improvement of primary care services be supported by the delivery of feedback and performance measurements. This paper describes the theory underlying an interprofessional educational intervention developed in Quebec’s Montérégie region (Canada) for the purpose of improving chronic disease management in primary care. The objectives of this study were to explain explicitly the theory underlying this intervention, to describe its components in detail and to assess the intervention’s feasibility and acceptability.MethodA program impact theory-driven evaluation approach was used. Multiple sources of information were examined to make explicit the theory underlying the education intervention: 1) a literature review and a review of documents describing the program’s development; 2) regular attendance at the project’s committee meetings; 3) direct observation of the workshops; 4) interviews of workshop participants; and 5) focus groups with workshop facilitators. Qualitative data collected were analysed using thematic analysis.ResultsThe theoretical basis of the interprofessional education intervention was found to be work motivation theory and reflective learning. Five themes describing the workshop objectives emerged from the qualitative analysis of the interviews conducted with the workshop participants. These five themes were the importance of: 1) adopting a regional perspective, 2) reflecting, 3) recognizing gaps between practice and guidelines, 4) collaborating, and 5) identifying possible practice improvements. The team experienced few challenges implementing the intervention. However, the workshop’s acceptability was found to be very good.ConclusionOur observation of the workshop sessions and the interviews conducted with the participants confirmed that the objectives of the education intervention indeed targeted the improvement of interprofessional collaboration and quality of care. However, it is clear that a three-hour workshop alone cannot lead to major changes in practice. Long-term interventions are needed to support this complex change process.

Effectiveness of past and current critical incident analysis on reflective learning and practice change

Medical Education 2011: 45: 894–904

Using reflective learning to improve the impact of continuing education in the context of work rehabilitation.

Reflective learning has been described as a promising approach for ameliorating the impact of continuing education (CE) programs. However, there are still very few studies that have investigated how occupational therapists use reflection to improve the integration of CE program content in their decision-making processes. The study objectives were to describe how these professionals, working in the sector of work rehabilitation, used reflective learning to integrate research evidence into their clinical decision-making process and to identify the factors that influenced the reflective learning process. A collaborative research study was conducted. Eight occupational therapists were recruited to participate to the group that was convened for 12 meetings and held during a 15-month period. The strategies used were critical analysis of ill-structured and authentic clinical situations, peer support, reflective journal writing and complementary reading. The group facilitator acted as a research evidence mentor and guided the group process. The data collected was analyzed using the grounded theory method. The reflective learning process, used by the participants, enabled them to change their perspective at six different stages in their decision-making process. The participants developed their ability to use different types of reflective thinking: introspection, concept attainment, self-attribution, problem solving, action planning and reorganization. The factors that most influenced learning were: ease in sharing experience, normative beliefs, coping with negative emotions, perceived self-efficacy, social support and risk taking. Results led to the development of the Model of Research Utilization Grounded in Critical Reflection.

Empowering occupational therapists to become evidence-based work rehabilitation practitioners.

OBJECTIVE Occupational therapists (OTs) engage in continuing education to integrate best available knowledge and skills into their practice. However, many barriers influence the degree to which they are currently able to integrate research evidence into their clinical decision making process. The specific objectives were to explore the clinical decision-making processes they used, and to describe the empowerment process they developed to become evidence-based practitioners. PARTICIPANTS Eight OTs, who had attended a four-day workshop on evidence-based work rehabilitation, were recruited to participate to a reflective practice group. METHODS A collaborative research methodology was used. The group was convened for 12 meetings and held during a 15-month period. The data collected was analyzed using the grounded theory method. RESULTS The results revealed the different decision-making modes used by OTs: defensive, repressed, cautious, autonomous intuitive and autonomous thoughtful. These modes influenced utilization of evidence and determined the stances taken toward practice change. Reflective learning facilitated their utilization of an evidence-based practice model through a three-level empowerment process: deliberateness, client-centeredness and system mindedness. CONCLUSIONS During the course of this study, participants learned to become evidence-based practitioners. This process had an impact on how they viewed their clients, their practice and the work rehabilitation system.

Protocol for a mixed studies systematic review on the implementation of the recovery approach in adult mental health services

Introduction Recovery is integral to mental health planning in G-8 countries including Canada. A recovery-oriented approach to care aims to promote personal empowerment, illness self-management and a life beyond services for people with serious mental illness (SMI), while reducing the financial burden associated with mental illness. Although there is a growing body of literature on recovery, no synthesis of research on the implementation of recovery into mental health services exists. Objectives The objective is to conduct a mixed studies systematic review on the operationalisation of recovery into mental health services for adults with SMI. It will inform the transformation of Canadian services to a recovery orientation, but may be applicable to other countries. Methods and analysis Seven databases including PubMed, Ovid Medline, Ovid Embase, Ovid PsycInfo, CINAHL, the Cochrane Library and Scopus will be searched for peer-reviewed empirical studies published from 1998 to December 2016. Systematic reviews and studies using quantitative, qualitative and mixed methodologies will be included. Secondary searches will be conducted in reference lists of all selected full text articles. Handsearches will also be performed in the tables of contents of three recovery-focused journals for the last 5 years. International experts in the field will be contacted for comments and advice. Data extraction will include identification and methodological synthesis of each study; definition of recovery; information on recovery implementation; facilitators and barriers and study outcomes. A quality assessment will be conducted on each study. The data will be synthesised and a stepwise thematic analysis performed. Ethics and dissemination Ethics approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) a 1-day symposium; (2) presentations in national and international conferences and to local stakeholders; (3) publications in peer-reviewed journals; (4) posts on the organisational websites.

Facilitating quality improvement in primary healthcare using performance feedback and action planning.

Background Optimizing primary healthcare requires changes at the system level, including professionals working together using quality improvement strategies, and accessing resources and support to implement these changes. Our team developed a complex intervention to support the transformation of regional primary care into a more integrated model. This intervention, named “COMPAS” (Collectif pour les Meilleures Pratiques et I’Amelioration des Soins et services en medecine de famille), is founded on a comprehensive approach to performance measurement. A focus on population-based assessment of care and action planning is used to facilitate the development of interprofessional and interorganizational collaboration, in order to engage primary care professionals in quality improvement. The objectives of this study were to explain explicitly the theory underlying this intervention, to describe its components in detail and to assess the intervention’s feasibility, acceptability and preliminary outcomes.

Professional portfolios used by Canadian occupational therapists: How can they be improved?

Professional portfolios are widely used in continuing professional development (CPD), despite limited evidence of their effectiveness for improving practice and professional competence. Occupational therapy regulatory organizations in Canada have implemented professional portfolios as tools that support engagement in CPD. To advance research and practice on the use of portfolios, we conducted a critical analysis of their format, content, and embedded learning process. This paper aims to describe and compare the portfolios’ characteristics when they are used as a tool to facilitate engagement in CPD. A document review approach was used to analyze documents describing continuing competence programs and portfolios and to compare their characteristics. Data was retrieved from documents using a coding scheme and content was compared to the literature. In Canada, seven out of 10 regulatory organizations have implemented a portfolio. They are similar in their content and proposed self-directed learning approach. Their strength is that they all promote self-assessment, reflection, and development of a CPD plan. However, the tools provided can be improved to help engage in more genuine reflection and integration of learning into practice. Our review of the content, tools, and proposed learning process of portfolios revealed avenues for improvement and future research.