Dawna Royall

Creating case scenarios or vignettes using factorial study design methods

AIMnThis paper is a report of a study conducted to develop clinical case vignettes using an adaptation of an incomplete factorial study design methodology.nnnBACKGROUNDnIn health care, vignettes or cases scenarios are core to problem-based learning, common in practice guideline development processes, and increasingly being used in patient or care-giver studies of chronic or life-threatening illnesses. A large number of behavioural, psycho-social and clinical factors can be relevant in such decision problems. Unbiased methods for choosing what factors to include are needed, when it is not possible to include all relevant combinations of factors in the vignettes.nnnMETHODnThe factors to be considered, number of levels or categories for each factor, and desired number of scenarios were decided in advance. An algorithm was used first to create the full factorial data set, and then a random subset of combinations was generated, according to predefined criteria, based on maximizing determinants. The subset of combinations was incorporated into written vignettes. The study was conducted in 2004-2005.nnnFINDINGSnApplication of the method yielded diverse and balanced scenarios that covered the full range of factors to be considered for a project to elicit health providers processes in diet counselling for dyslipidemia.nnnCONCLUSIONnThe approach is flexible, decreases possible researcher bias in the creation of vignettes, and can improve statistical power in survey research. This novel application of study design methodology merits consideration when vignettes are being developed to elicit opinions or decisions in studies of complex health issues.

Use of electronic dietary assessment tools in primary care: an interdisciplinary perspective

BackgroundDietary assessment can be challenging for many reasons, including the wide variety of foods, eating patterns and nutrients to be considered. In team-based primary care practice, various disciplines may be involved in assessing diet. Electronic-based dietary assessment (e-DA) instruments available now through mobile apps or websites can potentially facilitate dietary assessment. Providers views of facilitators and barriers related to e-DA instruments and their recommendations for improvement can inform the further development of these tools. The objective of this study was to explore provider perspectives on e-DA tools in mobile apps and websites.MethodsThe exploratory sequential mixed methods design included interdisciplinary focus groups followed by a web-based survey sent to Family Health Teams throughout Ontario, Canada. Descriptive and bivariate analyses were completed. Focus group transcripts contributed to web-survey content, while interpretive themes added depth and context.Results11 focus groups with 50 providers revealed varying perspectives on the use of e-DA for: 1) improving patients’ eating habits; 2) improving the quality of dietary assessment; and, 3) integrating e-DA into the care process. In the web-survey 191 respondents from nine disciplines in 73 FHTs completed the survey. Dietitians reported greater use of e-DA than other providers (63% vs.19%; p = .000) respectively. There was strong interest among disciplines in the use of e-DA tools for the management of obesity, diabetes and heart disease, especially for patient self-monitoring. Barriers identified were: patients’ lack of comfort with using technology, misinterpretation of e-DA results by patients, time and education for providers to interpret results, and time for providers to offer counselling.Conclusionse-DA tools in mobile apps and websites may improve dietary counselling over time. Addressing the identified facilitators and barriers can potentially promote the uptake of e-DA into clinical practice.

Obesity services planning framework for interprofessional primary care organizations

Aim We report on a formative project to develop an organization-level planning framework for obesity prevention and management services.nnnBACKGROUNDnIt is common when developing new services to first develop a logic model outlining expected outcomes and key processes. This can be onerous for single primary care organizations, especially for complex conditions like obesity.nnnMETHODSnThe initial draft was developed by the research team, based on results from provider and patient focus groups in one large Family Health Team (FHT) in Ontario. This draft was reviewed and activities prioritized by 20 FHTs using a moderated electronic consensus process. A national panel then reviewed the draft. Findings Providers identified five main target groups: pregnancy to 2, 3-12, 13-18, 18+ years at health risk, and 18+ with complex care needs. Desired outcomes were identified and activities were prioritized under categories: raising awareness (eg, providing information and resources on weight-health), identification and initial management (eg, wellness care), follow-up management (eg, group programs), expanded services (eg, availability of team services), and practice initiatives (eg, interprofessional education). Overall, there was strong support for raising awareness by providing information on the weight-health connection and on community services. There was also strong support for growth assessment in pediatric care. In adults, there was strong support for wellness care/health check visits and episodic care to identify people for interventions, for group programs, and for additional provider education.nnnCONCLUSIONSnJoint development by different teams proved useful for consensus on outcomes and for ensuring relevancy across practices. While priorities will vary depending on local context, the basic descriptions of care processes were endorsed by reviewers. Key next steps are to trial the use of the framework and for further implementation studies to find optimally effective approaches for obesity prevention and management across the lifespan.

Interprofessional dietary assessment practices in primary care: A mixed-methods study

ABSTRACT Patients in primary care (PC) are often counselled on diet, and assessment of current food intake is a necessary prerequisite for individualized nutrition care. This sequential mixed-methods study explored current diet assessment (DA) practices in team-based PC in Ontario, Canada, with interdisciplinary focus groups (FGs) followed by a web-based survey. Eleven FGs (n = 50) discussed key patient groups and health conditions requiring DA, as well as facilitators and barriers to accurate DA. Interpretative analysis revealed three themes: DA as a common activity that differed by health profession, communication of DA results within the team, and nutrition care as a collaborative team activity. A total of 191 providers from 73 Family Health Teams completed the web-based survey, and confirmed that many providers are frequently doing DA and that methods vary by discipline. Most providers conducted DAs every day or almost every day. As expected, dietitians used more formal and detailed methods to assess diet than other disciplines, who were more likely to ask a few pointed questions. These baseline data provide information on the range of current DA practices in team-based PC that can inform development of new, more accurate approaches that may improve counselling effectiveness.

Lifestyle genomics and the metabolic syndrome: A review of genetic variants that influence response to diet and exercise interventions

ABSTRACT Metabolic syndrome (MetS) comprises a cluster of risk factors that includes central obesity, dyslipidemia, impaired glucose homeostasis and hypertension. Individuals with MetS have elevated risk of type 2 diabetes and cardiovascular disease; thus placing significant burdens on social and healthcare systems. Lifestyle interventions (comprised of diet, exercise or a combination of both) are routinely recommended as the first line of treatment for MetS. Only a proportion of people respond, and it has been assumed that psychological and social aspects primarily account for these differences. However, the etiology of MetS is multifactorial and stems, in part, on a persons genetic make-up. Numerous single nucleotide polymorphisms (SNPs) are associated with the various components of MetS, and several of these SNPs have been shown to modify a persons response to lifestyle interventions. Consequently, genetic variants can influence the extent to which a person responds to changes in diet and/or exercise. The goal of this review is to highlight SNPs reported to influence the magnitude of change in body weight, dyslipidemia, glucose homeostasis and blood pressure during lifestyle interventions aimed at improving MetS components. Knowledge regarding these genetic variants and their ability to modulate a persons response will provide additional context for improving the effectiveness of personalized lifestyle interventions that aim to reduce the risks associated with MetS.

Patient experiences of a lifestyle program for metabolic syndrome offered in family medicine clinics: a mixed methods study

BackgroundPatient perspectives on new programs to manage metabolic syndrome (MetS) are critical to evaluate for possible implementation in the primary healthcare system. Participants’ perspectives were sought for the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) study, which enrolled 293 participants, and demonstrated 19% reversal of MetS after 1 year. The main purpose of this study was to examine participants’ perceptions of their experiences with the CHANGE program, enablers and barriers to change.MethodsA convergent parallel mixed methods design combined patients’ perspectives collected by questionnaires (nxa0=u2009164), with insights from focus groups (nxa0=u200941) from three sites across Canada. Qualitative data were thematically analyzed using interpretative description. Insights were organized within a socio-ecologic framework.ResultsKey aspects identified by participants included intra-individual factors (personal agency, increased time availability), inter-individual factors (trust, social aspects) and organizational factors (increased mental health support, tailored programs).ConclusionResults revealed participants’ overall support for the CHANGE program, especially the importance of an extended program under the guidance of a family physician along with a skilled and supportive team. Team delivery of a lifestyle program in primary care or family medicine clinics is a complex intervention and use of a mixed methods design was helpful for exploring patient experiences and key issues on enablers and barriers to health behavior change.

Care Gaps and Opportunities to Improve Risk Reduction Strategies of Women Diagnosed with Gestational Diabetes in Centre Wellington

Research Design and MethodsA retrospective chart review was done on patients meeting the following criteria: admitted to the medical or surgical ward at HSC between 2007 and 2011, previously diagnosed with type 1 or 2 diabetes mellitus, between 18 and 90 years of age and with a hospital stay between 8 and 30 days (inclusive). Blood glucose data and diabetes medication prior to and during hospitalization for each patient were extracted from the charts. Indicators of glycemic control in the first 5 days of hospital stay was compared to the level of control achieved in the remaining days at the hospital using a paired t-test. Results: (table): All indicators with the exception of % of values between 7 and 10 mmol/L and % below 4 mmol/L experienced a statistically significant improvement between the first five days and the remainder of days in the hospital stay.

Eliciting provider and patient perspectives to develop an interdisciplinary obesity management planning framework in primary care

D. Royall, P. Brauer, E. Ackah, J.J.M. Dwyer, A.M. Edwards, R. Goy, T. Hussey, and N. Kates Nutrition Research Consulting, Fergus, Ontario, Canada; Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, Ontario, Canada; Research Consultant, Guelph, Ontario, Canada; Department of Computing and Communications Services, University of Guelph, Guelph, Ontario, Canada; Hamilton Family Health Team, Hamilton, Ontario, Canada