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Biomedical subjects

Ian D Graham

Publications and source records attributed to Ian D Graham.

At least 19 recordsLinked to original sources
PubMed2006

Many quality measurements, but few quality measures assessing the quality of breast cancer care in women: a systematic review.

BACKGROUND: Breast cancer in women is increasingly frequent, and care is complex, onerous and expensive, all of which lend urgency to improvements in care. Quality measurement is essential to monitor effectiveness and to guide improvements in healthcare. METHODS: Ten databases, including Medline, were searched electronically to identify measures assessing the quality of breast cancer care in women (diagnosis, treatment, followup, documentation of care). Eligible studies measured adherence to standards of breast cancer care in women diagnosed with, or in treatment for, any histological type of adenocarcinoma of the breast. Reference lists of studies, review articles, web sites, and files of experts were searched manually. Evidence appraisal entailed dual independent assessments of data (e.g., indicators used in quality measurement). The extent of each quality indicator's scientific validation as a measure was assessed. The American Society of Clinical Oncology (ASCO) was asked to contribute quality measures under development. RESULTS: Sixty relevant reports identified 58 studies with 143 indicators assessing adherence to quality breast cancer care. A paucity of validated indicators (n = 12), most of which assessed quality of life, only permitted a qualitative data synthesis. Most quality indicators evaluated processes of care. CONCLUSION: While some studies revealed patterns of under-use of care, all adherence data require confirmation using validated quality measures. ASCO's current development of a set of quality measures relating to breast cancer care may hold the key to conducting definitive studies.

Breast Neoplasms↗
PubMed2006

Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice.

OBJECTIVE: To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice. METHODS: Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants. RESULTS: Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators. CONCLUSION: These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice. PRACTICE IMPLICATIONS: Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Adult↗
PubMed2006

Adoption and sustainability of decision support for patients facing health decisions: an implementation case study in nursing.

BACKGROUND: Effective interventions prepare patients for making values-sensitive health decisions by helping them become informed and clarifying their values for each of the options. However, patient decision support interventions have not been widely implemented and little is known about effective models for delivering them to patients. The purpose of this study was to describe call centre nurses' adoption of a decision support protocol into practice following exposure to an implementation intervention and to identify factors influencing sustainable nursing practice changes. METHODS: Exploratory case study at a Canadian province-wide call centre guided by the Ottawa Model of Research Use. Data sources included a survey of nurses who participated in an implementation intervention (n = 31), 2 focus groups with nurses, interviews with 4 administrators, and a document review. RESULTS: Twenty-five of 31 nurses responded to the survey measuring adoption of decision support in practice. Of the 25 nurses, 11 had used the decision support protocol in their practice within one month of the intervention. Twenty-two of the 25 intended to use it within the next three months. Although some nurses found it challenging to begin using the protocol, most nurses reported that it: a) helped them recognize callers needing decision support; b) changed their approach to handling these calls; and c) was a positive enhancement to their practice. Strategies identified to promote sustainability of practice changes included integration of the decision support protocol in the call centre database, streamlining the patient decision aids for easier use via telephone, clarifying the administrative direction for the call centre's program, creating a call length guideline specific for these calls, incorporating decision support training in the staff development plan, and informing the public of this enhanced service. CONCLUSION: Although most nurses adopted the decision support protocol for coaching callers facing values-sensitive decisions, to sustain practice changes, interventions are required to manage barriers in the practice environment and integrate decision support into the organization's policies, resources, and routine activities.

Journal Article↗
PubMed2006

Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions.

BACKGROUND: Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals. METHODS: Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed. RESULTS: Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from The Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28). CONCLUSION: This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.

Journal Article↗
PubMed2006

Oral cobalamin remains medicine's best kept secret.

A cross-sectional survey was conducted in order to describe the use of oral cobalamin among geriatricians, hematologists, and general practitioners, and to explore factors related to its use. The study population consisted of all geriatricians (n = 138) and hematologists (n = 317) listed in the Canadian Medical Directory plus a random sample of 307 general practitioners. The overall response rate was 40%. Intramuscular and oral cobalamin was prescribed by 76 and 32% of the respondents, respectively. Twenty seven percent reported using both oral and intramuscular cobalamin and 6% reported using only oral cobalamin. Only 25% of respondents indicated they were aware of a RCT demonstrating the efficacy of oral cobalamin prior to reading a synopsis of the study in the survey. After multivariate adjustment, only the belief that oral cobalamin was effective and certainty about who carried oral preparations remained independently associated with oral cobalamin use. Oral cobalamin has been shown to be an efficacious, cost efficient and safe method of treating cobalamin deficiency. Nonetheless, it is not used by the majority of physicians treating this condition. Strategies to promote the use of oral cobalamin should be directed at educating physicians of its efficacy and providing them with prescribing information on where it can be purchased.

Administration, Oral↗
PubMed2006

Print format and sender recognition were related to survey completion rate.

OBJECTIVE: To assess whether print format (single-sided vs. double) and sender recognition (known vs. unknown) affect response and completion rates among physician survey respondents. STUDY DESIGN AND SETTING: Postal survey of 399 members of the Canadian Association of Emergency Physicians; 2 x 2 factorial design. RESULTS: Response rate was 69.4%. Single-sided printing yielded 7.4% (odds ratio OR = 1.41; 95% confidence interval CI = 0.90-2.20; P = 0.13), and a known sender yielded a 6.3% greater response rate (OR = 0.73; 95% CI = 0.47-1.14; P = 0.16). Overall item completion was 98.2%; items missed per respondent ranged from 1 to 14 out of 50. Print format and sender recognition interacted in predicting completion rate (OR = 13.33; 95% CI = 3.10-57.4; P = 0.001); completion was higher for double-sided printing with an unknown sender, and for single-sided printing with a known sender. Completion was also lower when response came after later mailouts (chi2(2) = 10.13; P = 0.006). CONCLUSIONS: Print format and sender recognition both yielded 6%-7% (nonsignificant) response rate differences. Survey completion rate varied even when overall item completion was high. Completion rate was useful for identifying subgroups likely to provide incomplete data (i.e., late responders), and may provide important information for subsequent surveys. Combining factors that on their own improve survey response may have unexpected consequences.

Attitude of Health Personnel↗
PubMed2006

Will a new clinical decision rule be widely used? The case of the Canadian C-spine rule.

OBJECTIVES: The reasons why some clinical decision rules (CDRs) become widely used and others do not are not well understood. The authors wanted to know the following: 1) To what extent is widespread use of a new, relatively complex CDR an attainable goal? 2) How do physician perceptions of the new CDR compare with those of a widely used rule? 3) To what extent do physician subgroups differ in likelihood to use a new rule? METHODS: A survey of 399 Canadian emergency physicians was conducted using Dillman's Tailored Design Method for postal surveys. The physicians were queried regarding the Canadian Cervical-Spine Rule (C-Spine Rule). Results were analyzed via frequency distributions, tests of association, and logistic regression. RESULTS: Response rate was 69.2% (262/376). Most respondents (83.6%) reported having already seen the Canadian C-Spine Rule, while 63.0% reported already using it. Of those who did not currently use the rule, 74.2% reported that they would consider using it in the future despite the fact that, compared with another widely used rule (the Ottawa Ankle Rules), the C-Spine Rule was rated as less easy to learn (z = 6.68, p < 0.001), remember (z = 7.37, p < 0.001), and use (z = 5.90, p < 0.001). Those who had never seen the rule before were older (chi2(2) = 5.10, p = 0.007) and more likely to work part-time (chi2(2) = 7.31, p = 0.026). The best predictors of whether the rule would be used was whether it had first been seen during training (odds ratio [OR], 2.62; 95% confidence interval [CI] = 1.14 to 6.04), was perceived as an efficient use of time (OR, 4.44; 95% CI = 1.12 to 16.89), and was too much trouble to apply (OR, 0.25; 95% CI = 0.08 to 0.77). CONCLUSIONS: Widespread use of a relatively complex rule is possible. Older and part-time physicians were less likely to have seen the Canadian C-Spine Rule but not less likely to use it once they had seen it. Targeting hard-to-reach subpopulations while stressing the safety and convenience of these rules is most likely to increase use of new CDRs.

Algorithms↗
PubMed2006

Lost in knowledge translation: time for a map?

There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about planned-action theories to be better able to understand and influence change in practice settings.

Education, Continuing↗
PubMed2006

Identification of domains relevant to health-related quality of life in patients undergoing major surgery.

This study examined themes relevant to health-related quality of life as identified by patients undergoing major surgery and by health care providers. Semi-structured interviews were conducted with 52 patients undergoing major abdominal, cardiac, orthopedic, thoracic, or vascular surgical procedures and 33 health professionals from various disciplines. A total of 58 themes were identified by content analysis. These themes were categorized into 6 domains. These were: physical well-being (14 themes), emotional well-being (13 themes), concern about quality of care (12 themes), social well-being (12 themes), cognitive preparation (4 themes), and spiritual well-being (3 themes). In general, we found that most aspects of health-related quality of life were common across various major surgical procedures and between patients and health care providers. However, when we examined the coverage of these themes in seven commonly-used health-related quality of life instruments, we found that many of the most frequently mentioned themes were not assessed with the available measures. A new evaluative instrument tailored to patients undergoing major surgery may therefore be warranted.

Aged↗
PubMed2006

The Ottawa Hospital's Clinical Practice Guideline for the Second Stage of Labour.

The management of the second stage of labour remains controversial, and there are very few comprehensive evidence-based clinical practice guidelines to assist care providers. We describe an approach to developing a local clinical practice guideline that included extensive review of the literature; use of a guideline appraisal instrument to assess methodological rigour, content, clarity and applicability; use of a recommendation matrix; drafting a local guideline; obtaining formal feedback; making revisions; and designing an implementation and evaluation plan. Recommendations from this guideline include timelines for the total length of second stage, waiting time, and pushing time. Positioning of the woman, use of oxytocin, and fetal assessment are also discussed. This guideline is not intended to be used for women with multiple gestation and women attempting vaginal birth after Caesarean (VBAC) or in clinical situations where little evidence on best practice exists and management is individualized. We advocate an approach to the second stage of labour that enhances patient safety through team planning, communication, and documentation.

Evidence-Based Medicine↗
PubMed2006

Understanding and overcoming the barriers of implementing patient decision aids in clinical practice.

Patient decision aids (ptDAs) have been developed to assist patients with difficult health-related decisions. Despite their proven effects on decision quality in numerous efficacy trials, we lack an evidence-based approach for implementing them as part of the process of care. Pragmatic trials of ptDAs have uncovered a myriad of implementation challenges; therefore we need a better understanding of the barriers and strategies to overcome them to facilitate their widespread uptake. The following paper provides an overview of the barriers related to the uptake of ptDAs within the process of care and the strategies, opportunities and research priorities to overcome them. This report is based on our interpretation of the literature and our collective experience in implementing ptDAs within trials and other contexts.

Communication Barriers↗
PubMed2006

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD.

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Asthma↗
PubMed2006

Randomized controlled trial of the effectiveness of an intervention to implement evidence-based patient decision support in a nursing call centre.

We evaluated the effect of an intervention on call centre nurses' knowledge of decision support and skills in coaching callers facing value-sensitive health decisions. Forty-one registered nurses at a health call centre were randomly assigned to an intervention or control group. The intervention was a coaching protocol, online tutorial, skills building workshop and performance feedback. The main outcome measures were: knowledge test; blinded quality assessment of coaching skills during simulated calls and call duration. Compared with controls, nurses in the intervention group had better knowledge (74 versus 60%, P = 0.007) and decision coaching skills (81 versus 44%, P < 0.001), particularly in assessing decisional needs (information, values clarity, support, stage and timing of decision) and addressing support issues. Call duration did not differ (18.5 versus 16.7 min, P = 0.73). The coaching protocol was rated as compatible with nurses' views on decision-making and more advantageous compared with their usual practices. The intervention improved the quality of nurses' decision coaching without affecting call duration.

Canada↗
PubMed2005

Family physicians' perspectives regarding palliative radiotherapy.

PURPOSE: To assess family physicians' views on common indications for palliative radiotherapy and to determine whether this influences patient referral. METHODS AND MATERIALS: A 30-item questionnaire evaluating radiotherapy knowledge and training developed at the Ottawa Regional Cancer Centre (ORCC) was mailed to a random sample of 400 family physicians in eastern Ontario, Canada. The completed surveys were collected and analyzed, and form the basis of this study. RESULTS: A total of 172 completed surveys were received for a net response rate of 50% among practicing family physicians. Almost all of the physicians (97%) had recently seen cancer patients in their offices, with 85% regularly caring for patient with advanced cancer. Fifty-four percent had referred patients in the past for radiotherapy and 53% had contacted a radiation oncologist for advice. Physicians who were more knowledgeable about the common indications for palliative radiotherapy were significantly more likely to refer patients for radiotherapy (P < 0.01). Inability to contact a radiation oncologist was correlated with not having referred patients for radiotherapy (P < 0.01). Only 10% of the physicians had received radiotherapy education during their formal medical training. CONCLUSIONS: Many of the family physicians surveyed were unaware of the effectiveness of radiotherapy in a variety of common palliative situations, and radiotherapy referral was correlated with knowledge about the indications for palliative radiotherapy. This was not surprising given the limited education they received in this area and the limited contact they have had with radiation oncologists. Strategies need to be developed to improve continuing medical education opportunities for family physicians and to facilitate more interaction between these physicians and radiation oncologists.

Attitude of Health Personnel↗
PubMed2005

Clinical decision rules "in the real world": how a widely disseminated rule is used in everyday practice.

BACKGROUND: Widespread, appropriate use of clinical decision rules would result in many benefits for health care. While it is known that clinicians report using these rules, little is known about how the rules are actually used in everyday practice. OBJECTIVES: To conduct a survey of emergency physicians to examine whether they use the Ottawa Ankle Rules (OAR) consistently, exclusively, and accurately. METHODS: A postal survey was administered to 399 emergency physicians randomly selected from the membership list of the Canadian Association of Emergency Physicians using Dillman's tailored design method for postal surveys. Results were analyzed via frequency distributions and linear regression. RESULTS: Response rate was 69.7% (262 of 376 eligible respondents), of whom 99.2% were familiar with the OAR. Most physicians (89.6%) reported using the OAR always or most of the time in appropriate circumstances, while only 42.2% reported basing their decisions to order radiography primarily on the rule. Physicians reported considering non-rule factors that are not related to the presence of a fracture (e.g., swelling: 54%), and factors that add no more predictive value over and above the rule (e.g., age >55 years: 55.2%). While 82.4% reported not having reviewed the rule for months or years, only 30.9% of the respondents were able to correctly remember the components of the rule. Errors in remembering rule components were more common among part-time (beta = 0.18, p = 0.009) and older (beta = 0.18, p = 0.04) physicians, and those who do not apply the rule consistently (beta = 0.14, p = 0.04). CONCLUSIONS: Most physicians report using and applying the OAR consistently, but most report that the rule is not the primary determinant of their decisions. Most apply this rule without referring to memory aids, yet their memory for this simple rule is imperfect. Future work should study how different memory aid strategies might improve the accuracy of rule application and reduce the use of nonpredictive cues.

Adult↗
PubMed2005

Leg-ulcer care in the community, before and after implementation of an evidence-based service.

BACKGROUND: Leg ulcers usually occur in older patients, a growing population for which increasing health care resources are required. Treatment is mainly provided in patients' homes; however, patients often receive poorly integrated services in multiple settings. We report the results of a prospective study of a community-based care strategy for leg ulcers. METHODS: International practice recommendations and guidelines were adapted to make a new clinical protocol. The new model, for a dedicated service staffed by specially trained registered nurses, established initial and ongoing assessment time frames and provided enhanced linkages to medical specialists. Data were collected for 1 year before and after implementation; outcome measures included 3-month healing rates, quality of life and resource usage. RESULTS: Three-month healing rates more than doubled between the year before implementation (23% [18/78]) and the year afterward (56% [100/180]). The number of nursing visits per case declined, from a median of 37 to 25 (p = 0.041); the median supply cost per case was reduced from 1923 dollars to 406 dollars (p = 0.005). INTERPRETATION: Reorganization of care for people with leg ulcers was associated with improved healing and a more efficient use of nursing visits.

Delivery of Health Care, Integrated↗