nda C. Li

Quality of Nonpharmacological Care in the Community for People with Knee and Hip Osteoarthritis

Objective. To assess the quality of nonpharmacological care received by people with knee and/or hip osteoarthritis (OA) in the community and to assess the associated factors. Methods. We conducted a postal survey to evaluate 4 OA quality-of-care indicators for knee/hip OA: (1) advice to exercise; (2) advice to lose weight; (3) assessment for ambulatory function; and (4) assessment for nonambulatory function, including dressing, grooming, and arising from a seated position. Eligible participants were identified from the administrative database of British Columbia between 1992 and 2006. Results. In total, 1349 participants reported knee and/or hip OA [knee only = 700 (51.9%); hip only = 261 (19.3%); knee and hip = 388 (28.8%)]. Their mean age was 67.1 years (SD 11.1); 816 (60.5%) were women, and 921 (68.3%) were diagnosed with OA for 6 years or longer. The overall pass rate of the 4 quality indicators was 22.4% (95% CI 20.5, 24.3). The pass rate for the individual quality indicator ranged from 6.9% for assessment of nonambulatory function to 29.2% for receiving assessment of ambulatory function. Receiving exercise advice was associated with having a university degree (vs high school diploma; OR 3.10, 95% CI 2.00, 4.80). Receiving weight-loss advice was associated with being female (OR 2.64, 95% CI 1.71, 4.08), being aged 55–64 years (compared to being aged 75 and over; OR 1.96, 95% CI 1.02, 3.76), and having higher Western Ontario and McMaster Universities Osteoarthritis Index scores (for every 10-point increment; OR 1.14, 95% CI 1.02, 1.26). On the other hand, having less than a high school education reduced the odds of weight-loss advice (OR 0.52, 95% CI 0.30, 0.88). Conclusion. The quality of nonpharmacological care for people with knee/hip OA in the community is suboptimal. Advice on exercise and weight management may not be provided equally across sex, age, disability, and formal education levels.

Electronic communities of practice: guidelines from a project.

The timely incorporation of health research into the routine practice of individual health practitioners and interprofessional teams is a widely recognized and ongoing challenge. Health professional engagement and learning is an important cog in the wheel of knowledge translation; passive dissemination of evidence through journals and clinical practice guidelines is inadequate when used alone as an intervention to change the practices of the health professionals.An evolving body of research suggests that communities of practice can be effective in facilitating the uptake of best practices by individual health professionals and teams. Modern information technologies can extend the boundaries and reach of these communities, forming electronic communities of practice (eCoP) that can be used to promote intra- and interprofessional continuing professional development (CPD) and team-based, patient-centered care. However, examples of eCoPs and examination of their characteristics are lacking in the literature. In this paper, we discuss guidelines for developing eCoP. These guidelines will be helpful for others considering the use of the eCoP model in interprofessional learning and practice.

Delivering patient decision aids on the Internet: definitions, theories, current evidence, and emerging research areas

BackgroundIn 2005, the International Patient Decision Aids Standards Collaboration identified twelve quality dimensions to guide assessment of patient decision aids. One dimension—the delivery of patient decision aids on the Internet—is relevant when the Internet is used to provide some or all components of a patient decision aid. Building on the original background chapter, this paper provides an updated definition for this dimension, outlines a theoretical rationale, describes current evidence, and discusses emerging research areas.MethodsAn international, multidisciplinary panel of authors examined the relevant theoretical literature and empirical evidence through 2012.ResultsThe updated definition distinguishes Internet-delivery of patient decision aids from online health information and clinical practice guidelines. Theories in cognitive psychology, decision psychology, communication, and education support the value of Internet features for providing interactive information and deliberative support. Dissemination and implementation theories support Internet-delivery for providing the right information (rapidly updated), to the right person (tailored), at the right time (the appropriate point in the decision making process). Additional efforts are needed to integrate the theoretical rationale and empirical evidence from health technology perspectives, such as consumer health informatics, user experience design, and human-computer interaction.Despite Internet usage ranging from 74% to 85% in developed countries and 80% of users searching for health information, it is unknown how many individuals specifically seek patient decision aids on the Internet. Among the 86 randomized controlled trials in the 2011 Cochrane Collaboration’s review of patient decision aids, only four studies focused on Internet-delivery. Given the limited number of published studies, this paper particularly focused on identifying gaps in the empirical evidence base and identifying emerging areas of research.ConclusionsAs of 2012, the updated theoretical rationale and emerging evidence suggest potential benefits to delivering patient decision aids on the Internet. However, additional research is needed to identify best practices and quality metrics for Internet-based development, evaluation, and dissemination, particularly in the areas of interactivity, multimedia components, socially-generated information, and implementation strategies.

An evidence‐informed, integrated framework for rheumatoid arthritis care

Introduction Providing adequate care for persons with rheumatoid arthritis (RA) is an ongoing challenge. Although the current evidence supports the use of disease-modifying antirheumatic drugs (DMARDs) within the first 3 months of symptoms appearing (1–3), delay in DMARD use and other gaps in care have been reported across communities (4–9). The situation has worsened due to the shortage of specialists (10). The process of seeking medical treatment begins with the person’s recognition of the symptoms and the action of visiting a family physician (FP) (Figure 1, levels A and B). The FP then performs the appropriate investigations, and if RA is suspected, the FP refers the person to a rheumatologist (levels B and C) who then conducts further tests, provides a diagnosis, and prescribes DMARDs and other appropriate medications (level D). Next, the person may be referred to the available community resources and/or rehabilitation programs that enable self-management (levels E1–E4), and will be periodically assessed by a rheumatologist (level F). Successful delivery of these interventions is largely dependent on the availability of local programs and the coordination among the rheumatologist, the FP, and other health professionals. In the case of severe joint damage, the person is referred for an orthopedic consultation and surgery may be considered (levels G1–G4). Moving from one level to the next involves a potential wait period, which may be caused by, for example, delays in patients’ and health professionals’ recognition of RA symptoms, delays in referral to rheumatologists, lack of access to specialist care or community resources, or patients’ own choices. Delays may occur at any of the following periods (Figure 1): Wait 1: the time between a person’s development and awareness of the seriousness of the symptoms and the first visit with an FP; Wait 2: the time between the first visit with an FP and the first visit with a rheumatologist; Wait 3: from the first rheumatology visit to the date the patient starts the appropriate therapy; Wait 4: from a patient starting medication to the date when he or she has access to adequate resources that enable self-management; andWait 5: from the decision date for an orthopedic consultation to the date of the patient’s first visit with a surgeon and, subsequently, the date of surgery. The delay between symptom onset and DMARD prescription for individuals with RA is a problem across countries (Waits 1–3), with a median lag time ranging from 6.5 to 19 months (5–9). A few studies have attempted to estimate the length of Wait 1, but the findings are inconsistent. Two studies, a retrospective cohort from the US (11) and a prospective study from Norway (12), estimated a median delay of 4 weeks for the first FP visit. However, more recent research from the UK estimated 12 weeks (13), with 38% of people waiting more than 3 months before seeing an FP (14). The lag time from FP visit to rheumatologist consultation is believed to be a major source of the delay (Wait 2). In a UK study, 44% waited more than 3 months for a specialist referral (14). Recent research from Canada also found a median lag time of 79 days between the FP visit and the first rheumatologist visit (15). In contrast, the Linda C. Li, PT, PhD: University of British Columbia and Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada; Elizabeth M. Badley, DPhil: Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute and University of Toronto, Toronto, Ontario, Canada; Crystal MacKay, PT, MHSc: Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute, Toronto, Ontario, Canada; Dianne Mosher, MD, FRCP(C): Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada; Shahin (Walji) Jamal, MD, FRCP(C): St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada; Anamaria Jones, PT, PhD(Candidate): Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada, and Federal University of Sao Paulo, Sao Paulo, Brazil; Claire Bombardier, MD, FRCP(C): University Health Network, University of Toronto, Institute for Work & Health, and Mount Sinai Hospital, Toronto, Ontario, Canada. Dr. Mosher has received honoraria (less than

Qualitative Research Ethics: Enhancing Evidence-Based Practice in Physical Therapy

10,000) from serving on the advisory board for Pfizer, and has received speaking fees (less than

Everyday ethics and help-seeking in early rheumatoid arthritis

10,000 each) from Schering, Amgen, and Wyeth. Address correspondence to Linda C. Li, PT, PhD, Arthritis Research Centre of Canada, 895 West 10th Avenue, Room 324, Vancouver, British Columbia V5Z 1L7, Canada. E-mail: lli@arthritisresearch.ca. Submitted for publication December 27, 2007; accepted in revised form April 22, 2008. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 59, No. 8, August 15, 2008, pp 1171–1183 DOI 10.1002/art.23931

Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis.

Background Increasing challenges to health care systems and the prominence of patient-centered care and evidence-based practice have fostered the application of qualitative approaches in health care settings, prompting discussions of associated ethical issues in a range of disciplines. Objectives The purposes of this work were to identify and describe the application and value of qualitative health research for physical therapy and to identify ethical considerations in a qualitative research study. Design This was a qualitative interview study with telephone follow-ups. Methods Forty-six participants were interviewed about their early experiences with rheumatoid arthritis. They also were asked what motivated them to volunteer for the study. To inform the discussion of ethics in qualitative health research, this study drew on the in-depth interviews, took a descriptive approach to the data, and applied the traditional ethical principles of autonomy, justice, and beneficence to the study process. Results Ethical issues emerged in this qualitative health research study that were both similar to and different from those that exist in a positivist paradigm (eg, clinical research). With flexibility and latitude, the traditional principle approach can be applied usefully to qualitative health research. Conclusions These findings build on previous research and discussion in physical therapy and other disciplines that urge a flexible approach to qualitative research ethics and recognize that ethics are embedded in an unfolding research process involving the role of the subjective researcher and an active participant. We suggest reflexivity as a way to recognize ethical moments throughout qualitative research and to help build methodological and ethical rigor in research relevant to physical therapist practice.

eHealth, Participatory Medicine, and Ethical Care: A Focus Group Study of Patients' and Health Care Providers' Use of Health-Related Internet Information.

Background: Sociological understandings of chronic illness have revealed tensions and complexities around help-seeking. Although ethics underpins healthcare, its application in the area of chronic illness is limited. Here we apply an ethical framework to interview accounts and identify ethical challenges in the early rheumatoid arthritis (RA) experience. Methods: In-depth interviews were conducted with eight participants who had been diagnosed with RA in the 12 months prior to recruitment. Applying the concepts of autonomous decision-making and procedural justice highlighted ethical concerns which arose throughout the help-seeking process. Analysis was based on the constant-comparison approach. Results: Individuals described decision-making, illness actions and the medical encounter. The process was complicated by inadequate knowledge about symptoms, common-sense understandings about the GP appointment, difficulties concerning access to specialists, and patient—practitioner interactions. Autonomous decision-making and procedural justice were compromised. The accounts revealed contradictions between the policy ideals of active self-management, patient-centred care and shared decision-making, and the everyday experiences of individuals. Conclusions: For ethical healthcare there is a need for: public knowledge about early RA symptoms; more effective patient—practitioner communication; and increased support during the wait between primary and secondary care. Healthcare facilities and the government may consider different models to deliver services to people requiring rheumatology consults.

Self-management interventions in the digital age: New approaches to support people with rheumatologic conditions

To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.

Recruitment and retention of occupational therapists and physiotherapists in rural regions: a meta-synthesis

Background The rapid explosion in online digital health resources is seen as transformational, accelerating the shift from traditionally passive patients to patients as partners and altering the patient–health care professional (HCP) relationship. Patients with chronic conditions are increasingly engaged, enabled, and empowered to be partners in their care and encouraged to take responsibility for managing their conditions with HCP support. Objective In this paper, we focus on patients’ and HCPs’ use of health-related Internet information and how it influences the patient-HCP relationship. In particular, we examine the challenges emerging in medical encounters as roles and relationships shift and apply a conceptual framework of relational ethics to examine explicit and nuanced ethical dimensions emerging in patient-HCP interactions as both parties make increased use of health-related Internet information. Methods We purposively sampled patients and HCPs in British Columbia, Canada, to participate in focus groups. To be eligible, patients self-reported a diagnosis of arthritis and at least one other chronic health condition; HCPs reported a caseload with >25% of patients with arthritis and multimorbidity. We used a semistructured, but flexible, discussion guide. All discussions were audiotaped and transcribed verbatim. Elements of grounded theory guided our constant comparison thematic analytic approach. Analysis was iterative. A relational ethics conceptual lens was applied to the data. Results We recruited 32 participants (18 patients, 14 HCPs). They attended seven focus groups: four with patients and three with rehabilitation professionals and physicians. Predominant themes to emerge were how use of health-related Internet information fostered (1) changing roles, (2) patient-HCP partnerships, and (3) tensions and burdens for patients and HCPs. Conclusions Relational aspects such as mutual trust, uncertainty, and vulnerability are illuminated in patient-HCP interactions around health-related Internet information and the negotiated space of clinical encounters. New roles and associated responsibilities have key ethical dimensions that make clear the changes are fundamental and important to understand in ethical care. When faced with tensions and burdens around incorporating health-related Internet information as a resource in clinical encounters, participants described a particular ambivalence illustrating the fundamental changes being negotiated by both patients and HCPs.