Doug Klein

CPD and KT: Models Used and Opportunities for Synergy

&NA; The two fields of continuing professional development (CPD) and knowledge translation (KT) within the health care sector, and their related research have developed as somewhat parallel paths with limited points of overlap or intersection. This is slowly beginning to change. The purpose of this paper is to describe and compare the dominant conceptual models informing each field with the view of increasing understanding and appreciation of the two fields, how they are similar and where they differ, and the current and potential points of intersection. The models include the “knowledge‐to‐action” (KTA) cycle informing KT, models informing CPD curriculum design and individual self‐directed learning, and the Kirkpatrick model for evaluating educational outcomes. When compared through the perspectives of conceptual designs, processes, and outcomes, the models overlap. We also identify shared gaps in both fields (eg, the need to explore the influence of the context in which CPD and KT interventions take place) and suggest opportunities for synergies and for moving forward.

Videoconferences for rural physicians’ continuing health education

The University of Alberta uses videoconferencing to link physicians in interactive continuing health education. We examined evaluations of 29 videoconferences for rural practitioners during the programme year September 2003–May 2004. The evaluation form, completed by participants following the presentation, used both quantitative and qualitative methods of data collection. The average attendance for the videoconference sessions was 40 people. A total of 593 evaluations were collected (response rate 51%). The audience were very satisfied with the programme and felt that the sessions were relevant to their practice. The interactive discussion component was rated very highly. Most respondents stated that they would change their practice based on the information discussed. It is clear from our survey that videoconferencing is useful in overcoming the barriers of distance and that small physician numbers create a positive environment for adult learning.

Using electronic clinical practice audits as needs assessment to produce effective continuing medical education programming

Background: The traditional needs assessment used in developing continuing medical education programs typically relies on surveying physicians and tends to only capture perceived learning needs. Instead, using tools available in electronic medical record systems to perform a clinical audit on a physicians practice highlights physician-specific practice patterns. Aim: The purpose of this study was to test the feasibility of implementing an electronic clinical audit needs assessment process for family physicians in Canada. Method: A clinical audit of 10 preventative care interventions and 10 chronic disease interventions was performed on family physician practices in Alberta, Canada. The physicians used the results from the audit to produce personalized learning needs, which were then translated into educational programming. Results: A total of 26 family practices and 4489 patient records were audited. Documented completion rates for interventions ranged from 13% for ensuring a patients tetanus vaccine is current to 97% of pregnant patients receiving the recommended prenatal vitamins. Conclusions: Electronic medical record-based needs assessments may provide a better basis for developing continuing medical education than a more traditional survey-based needs assessment. This electronic needs assessment uses the physicians own patient outcome information to assist in determining learning objectives that reflect both perceived and unperceived needs.

Family physician-led, team-based, lifestyle intervention in patients with metabolic syndrome: results of a multicentre feasibility project

BACKGROUND Metabolic syndrome (MetS) is a medical condition with major complications and health care costs. Previous research has shown that diet and exercise can improve and reverse this condition. The goal of this study was to test the feasibility and effectiveness of implementing the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) program into diverse family medicine practices to improve MetS. METHODS In this longitudinal before-after study, 305 adult patients with MetS were recruited from 3 diverse family medicine team-based organizations to the CHANGE personalized diet and exercise program. Participants were followed for 12 months. Primary outcomes included feasibility and reversal of MetS. Secondary outcomes included improvement in MetS components, changes in diet quality, aerobic fitness and cardiovascular risk. RESULTS Participants attended 76% and 90% of the kinesiologist and dietitian visits, respectively. At 12 months, 19% of patients (95% confidence interval [CI] 14%-24%) showed reversal of MetS, VO2max increased by 16% (95% CI 13%-18%), and Healthy Eating Index and Mediterranean Diet Scores improved by 9.6% (95% CI 7.6%-11.6%) and 1.4% (1.1%-1.6%), respectively. In addition, the Prospective Cardiovascular Munster (PROCAM) 10-year risk of acute coronary event decreased by 1.4%, from a baseline of 8.6%. INTERPRETATION A team-based program led by the family physician that educates patients about the risks of MetS, and with a dietitian and kinesiologist, empowers them to undertake an individualized supervised program of diet modification and exercise, is feasible, improves aerobic capacity and diet quality, reverses MetS and improves MetS components at 12 months.

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.

Electronic activity trackers encourage family fun and fitness.

E-health has been touted as the “single-most important revolution in healthcare since the advent of modern medicine, vaccines or even public health measures like sanitation and clean water”.1 Common areas of e-health include telemedicine, electronic patient records, computer-assisted surgery, and monitoring systems that are portable and/or wearable such as activity trackers.1 Some primary care physicians are engaging patients in self-monitoring, and goal setting through the use of novel e-health technologies.2,3 In 2013, wearable health-tracking technologies generated over US

Metabolic syndrome and weight management programs in primary care: a comparison of three international healthcare systems

1.6 billion, a number which is expected to rise to US

Recognizing difficult trade-offs: values and treatment preferences for end-of-life care in a multi-site survey of adult patients in family practices

5 billion by 2016.4 Current physical activity guidelines for adults aged 18–64 include at least 150 minutes of moderate aerobic exercise weekly, completed in intervals of at least 10 minutes, combined with at least two days per week of strength or resistance training.5 Unfortunately, few adults meet these physical activity recommendations.6 For children, the recommendations are for 60 minutes each day of moderate or vigorous intensity physical activity. Although active play and organised sport is common for some children, computers, hand-held devices, and decreasing school physical education class time may be contributing to our children becoming increasingly sedentary. A year ago, I started a project with some of my patients using electronic physical activity (PA) trackers. While I used Fitbit activity trackers, other companies have developed electronic PA trackers, including: Garmin, Jawbone, Nike, to name a few. As the Fitbit device is a piece of technology, my six-year-old son was very interested in learning how it works and decided it was his job to monitor my progress. In fact, he became a little obsessive about it by checking my step count several times each day. A few months ago, he began asking if he could have a Fitbit. Since his birthday was coming up, my wife and I thought it would be fun for him to get one. Well lo and behold… he loved it. He wore it everywhere, including in his bed, to ensure he tracked all his steps. He was also very interested in seeing whether or not he was beating me with his daily step count. Shortly afterwards, we were planning an extended six-month family trip where we would be doing significant amounts of walking. We thought that perhaps the Fitbit devices could encourage each of our three children to do more walking than is typical and hopefully minimise the complaints that sometimes arise when children are not as keen to cover the same distances as their parents. The results were amazing. Our children loved their activity trackers. They were very keen to go for hikes or walks around the various cities. Our son, who often tells us that his “legs are broken” in the hope of having me carry him on my back, wanted to make sure he “gets in 10,000 steps” daily. Our younger daughter (age 10) asked to go for a walk after a long day of walking (e.g., 22,000 steps) so she could reach a new record and get a new digital badge for her daily steps. At the end of other days, we would find our 12-year-old daughter walking around in circles. When we asked her what she was doing, she told us that she had not reached 10,000 steps that day and needed to keep moving until she reached that goal. Even after six months they had not lost interest in attaining their daily totals. Although PA technologies are fairly new and still developing, the evidence supporting their potential health benefits is starting to be described. One study examined the effect of using FitLinxx pedometers to track how many steps patients took, which was linked to computer software comparing the steps taken against exercise goals. Motivational tips were sent to patients via text message.4 The study found that patients who received these tips had better outcomes with controlling aspects of their health than those who did not receive the tips.4 Another study found that participants using pedometers significantly decreased their BMI and blood pressure and increased their physical activity by 2,000 steps per day.2 Additionally, the study concluded that the use of pedometers resulted in clinically significant reductions in weight.2 Several other studies, including a recent Cochrane systematic review, have demonstrated improved lifestyle and functional outcomes when using Internet-based interventions, pedometers, and logging physical activity electronically.2,7–9 Here are a few insights my wife and I have learned as parents of children who have used electronic activity trackers: Children are naturally more active than adults. On regular days, my wife and I would need to go out for a run for at least 45 minutes to keep up with the step-count our kids get by playing. Children are naturally competitive. Actually most people are the same. Our children are checking their step-count frequently throughout the day and want to be ahead of their siblings and their parents. Through the use of electronic activity, our children often would have the motivation to be more active so that they could catch up to another family member. Our teenage daughter would just go out for a walk on her own so that she could get more steps in during the day. The PA monitors have been a great way to encourage personal connections. Our children have enhanced their intergenerational ties. The children have been able to connect, compete, and cheer on their aunts, uncles, and grandparents through the friendly competition created by setting up a family group. Likewise, it can also encourage physical activity amongst peers. Our eldest daughter’s friend recently set up a challenge amongst four of her friends to see who could be the most active within a 24-hour period. Our children described wearing their Fitbit as “fun” because they can earn badges and get positive feedback on the computer. They also reported that the Fitbit encourages them to get more steps so that they can beat other people. Although these novel technologies have the potential benefits to improve physical activity, there are also potential downsides. Concerns range from the privacy of patient information to the technical and reliable collection and analysis of data. The uploading of personal patient data to apps and online tracking websites raises concerns over the potential misuse of patient information.4 Some of the devices do not track all exercise activities; for example, cycling and swimming. Several systems have the ability to log these other activities manually, but clearly this is less convenient. In addition, despite the decreased price of these devices, their cost may be prohibitive for many people and families. Despite privacy and usability concerns, healthcare providers continue to believe that these activity trackers and gadgets could revolutionise medical care and introduce a new wave of personalised medicine.4 Certainly, our experience with these electronic devices demonstrate their benefits by creating a fun, competitive way to encourage family physical activity, which can be beneficial to all involved.

Guideline harmonization and implementation plan for the BETTER trial: Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice

Lifestyle behaviours are contributing to the increasing incidence of chronic disease across all developed countries. Australia, Canada and the UK have had different approaches to the role of primary care in the prevention and management of lifestyle-related diseases. Both obesity and metabolic syndrome have been targeted by programs to reduce individual risk for chronic disease such as type 2 diabetes. Three interventions are described - for either obesity or metabolic syndrome - that have varying levels of involvement of GPs and other primary care professionals. The structure of a healthcare system for example, financing and physical locations of primary care clinicians, shapes the development of primary care interventions. The type of clinicians involved in interventions, whether they work alone or in teams, is influenced by the primary care setting and resource availability. Australian clinicians and policymakers should take into account the healthcare system where interventions are developed when translating interventions to the Australian context.

Advance care planning: Let's start sooner.

BackgroundDecisions about care options and the use of life-sustaining treatments should be informed by a person’s values and treatment preferences. The objective of this study was to examine the consistency of ratings of the importance of the values statements and the association between values statement ratings and the patient’s expressed treatment preference.MethodsWe conducted a multi-site survey in 20 family practices. Patients aged 50 and older self-completed a questionnaire assessing the importance of eight values (rated 1 to 10), and indicated their preference for use of life-sustaining treatment (5 options). We compared correlations among values to a priori hypotheses based on whether the value related to prolonging or shortening life, and examined expected relationships between importance of values and the preference option for life-sustaining treatment.ResultsEight hundred ten patients participated (92% response rate). Of 24 a priori predicted correlations among values statements, 14 were statistically significant but nearly all were negligible in their magnitude and some were in the opposite direction than expected. For example, the correlation between importance of being comfortable and suffering as little as possible and the importance of living as long as possible should have been inversely correlated but was positively correlated (r = 0.08, p = 0.03). Correlations between importance of values items and preference were negligible, ranging from 0.03 to 0.13.ConclusionsPatients may not recognize that trade-offs in what is most important may be needed when considering the use of treatments. In the context of preparation for decision-making during serious illness, decision aids that highlight these trade-offs and connect values to preferences more directly may be more helpful than those that do not.