Biomedical subjects

Vivek Goel

Publications and source records attributed to Vivek Goel.

At least 19 recordsLinked to original sources

PubMed2004

Evidence-based health policy: context and utilisation.

Evidence-based decision-making is centred on the justification of decisions. In the shift from an individual-clinical to a population-policy level, the decision-making context becomes more uncertain, variable and complex. To address this we have developed a conceptual framework for evidence-based decision-making, focusing on how context impacts on what constitutes evidence and how that evidence is utilised. We present two distinct orientations towards what constitutes evidence, representing different relationships between evidence and context. We also categorise the decision-making context based on the ways in which context impacts on evidence-based decision-making. Furthermore, we invoke the concept of axes of evidence-based decision-making to describe the relationship between evidence and context as we move from evidence-based medicine to evidence-based health policy. From this, we suggest that it may be more important how evidence is utilised than how it is defined. Based on the research and knowledge utilisation literature, we present a process model of evidence utilisation, which forms the basis for the conceptual framework for context-based evidence-based decision-making. The conceptual framework attempts to capture the role that context plays in the introduction, interpretation and application of evidence. We illustrate this framework with examples from policy development for colorectal cancer screening.

Colonic Neoplasms↗

PubMed2003

Feasibility study of multidisciplinary oncology rounds by videoconference for surgeons in remote locales.

BACKGROUND: This study was undertaken to assess the feasibility of using videoconferencing to involve community-based surgeons in interactive, multidisciplinary oncology rounds so they may benefit from the type of community of practice that is usually only available in academic cancer centres. METHODS: An existing videoconference service provider with sites across Ontario was chosen and the series was accredited. Indirect needs assessment involved examining responses to a previously conducted survey of provincial surgeons; interviewing three cancer surgeons from different regions of Ontario; and by analyzing an online portfolio of self-directed learning projects. Direct needs assessment involved a survey of surgeons at videoconference-enabled sites. A surgical, medical and radiation oncologist plus a facilitator were scheduled to guide discussion for each session. A patient scenario developed by the discussants was distributed to participants one week prior to each session. RESULTS: Direct and indirect needs assessment confirmed that breast cancer and colorectal cancer topics were of greatest importance to community surgeons. Six one-hour sessions were offered (two breast, two colorectal, one gynecologic and one lung cancer). A median of 22 physicians and a median of eight sites participated in each session. The majority of respondents were satisfied with the videoconference format, presenters and content. Many noted that discussion prompted reflection on practice and that current practice would change. CONCLUSIONS: This pilot study demonstrated that it is possible to engage remote surgeons in multidisciplinary oncology rounds by videoconference. Continued assessment of videoconferencing is warranted but further research is required to develop frameworks by which to evaluate the benefits of telehealth initiatives.

Data Collection↗

PubMed2003

Association between extent of axillary lymph node dissection and patient, tumor, surgeon, and hospital factors in patients with early breast cancer.

BACKGROUND AND OBJECTIVES: Axillary lymph node dissection (ALND) in patients with breast cancer is crucial for accurate staging, provides excellent regional tumor control, and is included in the standard of care for the surgical treatment of breast cancer. However, the extent of ALND varies, and the extent of dissection and the number of lymph nodes that comprise an optimal axillary dissection are under debate. Despite conflicting evidence, several studies have shown that improved survival is correlated with more lymph nodes removed in both node-negative and node-positive patients. The purpose of this study is to determine which patient, tumor, surgeon, and hospital characteristics are associated with the number of nodes excised in early breast cancer patients. METHODS: A random sample of 938 women with node-negative breast cancer was drawn from the Ontario Cancer Registry and the data supplemented with chart reviews. The extent of axillary dissection was studied by examining the number of nodes examined in relation to the patient, tumor, surgeon, and hospital factors. RESULTS: The mean number of lymph nodes excised was 9.8 (SD = 4.8; range, 1-31), and 49% of patients had >/=10 nodes excised. Lower patient age was associated with the excision of more lymph nodes (>/=10 nodes: 63% of patients <40 years vs. 38% of patients >/=80 years). Surgeon academic affiliation and surgery in a teaching hospital were highly correlated with each other and were significantly associated with the excision of >/=10 nodes. The number of nodes excised was not associated with any tumor factors, nor with the breast operation performed. These results were confirmed with multivariable models. CONCLUSIONS: Even though the number of lymph nodes found in the pathologic specimen can be influenced by factors other than surgical technique (e.g., number of nodes present, specimen handling, and pathologic examination), this study shows significant variation of this variable and an association with several patient and surgeon/hospital factors. This variation and the association with survival warrant further study and effort at greater consistency.

Academic Medical Centers↗

PubMed2003

Use of complementary/alternative medicine by men diagnosed with prostate cancer: prevalence and characteristics.

OBJECTIVES: To ascertain the prevalence of the use of complementary/alternative medicine (CAM) among a random sample of Ontario (Canadian) men diagnosed with prostate cancer and to explore in what way users of CAM differ from nonusers. METHODS: A questionnaire was mailed to a random sample of 696 men diagnosed with prostate cancer. RESULTS: The final response rate was 78.8%. Almost one third (29.8%) reported using CAM for their prostate cancer care. Natural health products (most commonly vitamin E, saw palmetto, and selenium) were used by 26.5% of the respondents. CAM therapies were used by 17.0% of the men (most commonly dietary changes), and only 9.1% visited CAM practitioners. Three characteristics appear to differentiate CAM users from nonusers. Men who had attended support groups were much more likely to use CAM. Men who had more advanced disease, and those who believed in the efficacy of CAM, but were not concerned about potential adverse effects of CAM, were also more likely to use CAM. CAM use was not related to education, income, or geographic location. CONCLUSIONS: The data suggest that CAM use is no longer a phenomenon restricted to a unique segment of the population that is highly educated and enjoys a high family income. CAM use appears to be more related to other factors such as support group attendance, disease characteristics, and beliefs about CAM. Our findings highlight the need for urologists to ask all their patients about their use of CAM.

Adenocarcinoma↗

PubMed2003

Relatives of colorectal cancer patients: factors associated with screening behavior.

BACKGROUND: The purpose of this study was to identify whether decisions regarding colorectal cancer (CRC) screening by relatives of CRC patients are influenced by social interactions with family members, friends, and physicians or by public awareness campaigns. METHODS: Screened (n=236) and nonscreened (n=132) relatives of CRC patients were interviewed in 2001. A socioecologic model was used as the framework for the interview variables, which included interactions with relatives, medical professionals, and social groups, as well as perceived benefits and barriers to screening and perceived susceptibility. RESULTS: Physician encouragement, fewer barriers to screening, strong CRC family history, encouragement from relatives, advice from a surgeon, and discussion of CRC screening with social groups were all associated with ever having been screened. Having been encouraged by a physician was the strongest correlate of screening behavior. Perceived susceptibility to CRC, advice from family members, and exposure to public awareness information were not associated with screening. CONCLUSIONS: The socioecologic framework is a good explanatory model of CRC screening in increased-risk relatives, as variables from each level were associated with screening. These findings can guide interventions aimed at increasing screening uptake, particularly those involving physicians.

Adult↗

PubMed2003

Comparison of methods to identify outliers observed in health services small area variation studies.

Small area variation analysis (SAV) is an established methodology in health services and epidemiological research. The goal is to demonstrate that rates differ across areas, and to explain these differences by differences in physician practice styles or patient characteristics. While the SAV statistics provide an overall variation estimate, they do not provide a statistical means to identify significant outliers. We compared the chi-square (chi2) test with three approaches in determining significant outliers in SAV. We used data from the Canadian Institute for Health Information (CIHI) for Ontario residents discharged between 1989 and 1991. Coronary artery bypass surgery, hysterectomy and hip replacement data were used to compare four statistics in determining outliers: the chi2 test, Swift's approximate bootstrap confidence interval (ABC), Carriere's T2 (T2) with simultaneous confidence intervals (SCI), and Gentleman's normalized scores (GNS). Both the ABC and SCI correct the skewness of the distribution of the adjusted rates. With large data, confidence intervals calculated by the normal or the ABC methods are indistinguishable. The T2 can be applied to also nonbinary events. For binary events, it is asymptotically the same as the chi2. The GNS ranks the rates, but the distribution of these ranks does not differ significantly from that of the adjusted rates. We concluded that when using large data with binary events, there is little advantage in using the ABC, SCI or GNS over the commonly known chi2. The chi2 remains a useful tool in small area variation analysis to 'screen' or flag potential differences beyond chance alone.

Arthroplasty, Replacement, Hip↗

PubMed2003

Utilization of complementary/alternative services by women with breast cancer.

This paper reports on the utilization of complementary/alternative medicine (CAM) services by women with breast cancer. Study participants were women with invasive breast cancer diagnosed 23-36 months prior to contact about the study, and randomly selected from the Ontario Cancer Registry. From among 1,119 eligible women sent survey questionnaires, 731 returned completed questionnaires (65%). A total of 20% of respondents used at least 1 CAM service. Among those who responded to a question about whether they would have liked specific services, 39% reported that there was at least one CAM service they would have liked to use, but were unable to access. Factors shown to be related to greater utilization of services included: younger age, higher household income, employed or student status, private health insurance coverage, and having received chemotherapy. Study results speak to the importance of acknowledging that professionals outside of the formal cancer care system play an important role for many patients. Patients would welcome experimentation with service models in which CAM practitioners and cancer specialists collaborate in providing care.

Aged↗

PubMed2003

Educating women about breast cancer. An intervention for women with a family history of breast cancer.

OBJECTIVE: To evaluate an "information aid" for women with a family history of breast cancer. DESIGN: Before-after descriptive study. SETTING: Family practices in Ontario. PARTICIPANTS: Of 405 randomly selected Ontario physician members of the College of Family Physician's of Canada's National Research System, 97 agreed to participate and to recruit three consecutive female patients with any family history of breast cancer. INTERVENTIONS: Patients completed a baseline questionnaire and, after reviewing the information aid, a satisfaction questionnaire. Four weeks later, they completed a third questionnaire. MAIN OUTCOME MEASURES: Patient satisfaction, knowledge, worries related to breast cancer, risk perception, and attitudes toward screening. RESULTS: Of 203 patients recruited, 160 (79%) completed all three questionnaires. The information aid was rated excellent or very good by 91% of the women; 99% would recommend it to other women. Knowledge improved significantly; worry about breast cancer did not increase. CONCLUSION: The information aid is a useful resource for women and primary care physicians and could facilitate appropriate risk assessment and management of women with a family history of breast cancer.

Adult↗

PubMed2003

A comparison of self-reported colorectal cancer screening with medical records.

The purpose of this study was to compare self-reports of colorectal cancer (CRC) screening by fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy with medical records in a multiprovider health care setting. Relatives of CRC patients residing in Ontario, Canada completed a questionnaire indicating whether or not they had ever had any CRC screening tests. Medical records from physician's offices and hospitals were compared with the self reports, and where possible, reasons were obtained for nonmatching reports. Medical records for colonoscopies were readily available from various sources, and self-reports of this procedure were very accurate (kappa statistic for agreement beyond chance = 0.87). For sigmoidoscopy and FOBT, the agreement was poorer (kappa = 0.29 and 0.32, respectively); however, there were difficulties in obtaining records for these two procedures. Sigmoidoscopy procedures that took place many years ago were difficult to document, and physician's offices were unable to provide FOBT reports in many cases. Self-reports of colonoscopy were very accurate in this population, whereas self-reports of sigmoidoscopy and FOBT are somewhat less accurate, although this is likely due to challenges in obtaining a confirmatory record rather than an overreporting of tests. In a multiprovider publicly insured health care setting such as Canada, using self-reported information is likely to provide sufficiently accurate information for colonoscopy, but for other CRC screening tests, there may be difficulty in obtaining true estimates of the frequencies of these procedures.

Colonoscopy↗

PubMed2002

A proposal for cervical screening information systems in developing countries.

The effective and efficient delivery of cervical screening programs requires information for planning, management, delivery and evaluation. Specially designed systems are generally required to meet these needs. In many developing countries, lack of information systems constitutes an important barrier to development of comprehensive screening programs and the effective control of cervical cancer. Our report outlines a framework for creating such systems in developing countries and describes a conceptual model for a cervical screening information system. The proposed system is modular, recognizing that there will be considerable between-region heterogeneity in current status and priorities. The proposed system is centered on modules that would allow for the assembly and computerization of data on Pap tests, since these represent the main screening modality at the present time. Additional modules would process data and create and maintain a screening database (e.g., standardize, edit, link and update modules) and allow for the integration of other types of data, such as cervical histopathology results. An open systems development model is proposed, since it is most compatible with the goals of local stakeholder involvement and capacity-building.

Databases as Topic↗

PubMed2002

Medical informatics in an undergraduate curriculum: a qualitative study.

BACKGROUND: There is strong support for educating physicians in medical informatics, and the benefits of such education have been clearly identified. Despite this, North American medical schools do not routinely provide education in medical informatics. METHODS: We conducted a qualitative study to identify issues facing the introduction of medical informatics into an undergraduate medical curriculum. Nine key informants at the University of Toronto medical school were interviewed, and their responses were transcribed and analyzed to identify consistent themes. RESULTS: The field of medical informatics was not clearly understood by participants. There was, however, strong support for medical informatics education, and the benefits of such education were consistently identified. In the curriculum we examined, medical informatics education was delivered informally and inconsistently through mainly optional activities. Issues facing the introduction of medical informatics education included: an unclear understanding of the discipline; faculty and administrative detractors and, the dense nature of the existing undergraduate medical curriculum. CONCLUSIONS: The identified issues may present serious obstacles to the introduction of medical informatics education into an undergraduate medicine curriculum, and we present some possible strategies for addressing these issues.

Academic Medical Centers↗

PubMed2002

Supportive care provided by physicians and nurses to women with breast cancer. Results from a population-based survey.

Breast cancer patients' utilisation of supportive care has been understudied. In this paper, results from a population-based survey are used to assess the role of physicians and nurses in providing supportive care to women. Participants for this study were women with histologically confirmed invasive breast cancer diagnosed 23-36 months prior to contact about the study, who were randomly selected from the Ontario Cancer Registry. Patients for whom a physician approved contact were sent a survey questionnaire. There were two follow-up mailings. The survey included items related to patients' perceptions of supportive care involvement of oncologists, surgeons, family physicians and nurses. Among 1,119 eligible patients, 65% returned completed questionnaires. A total of 72% of these women reported having talked with an oncologist about one or more supportive care issues; 78% with a surgeon; 73% with a family physician; and 45% with a nurse. Factors linked to seeking supportive care from physicians and/or nurses included: younger age, working status, higher education, additional health insurance beyond that provided by government, higher household income, and receiving chemotherapy. Results indicate that physicians and nurses were providing important supportive care to most women with breast cancer. In a health care context where specialised supportive care services (e.g. help from dietitians, psychologists, social workers) are often unavailable or difficult to access, supportive care remains largely a responsibility of medical and nursing professionals. Even brief interventions may make an important difference to how patients deal with their illness over time.

Adult↗

PubMed2002

Prophylactic bilateral mastectomy: patterns of practice.

BACKGROUND: Many women who are at an elevated risk of developing breast carcinoma choose prophylactic mastectomy to decrease their risk. We conducted a population-based study to review the indications for, and patterns of practice of prophylactic mastectomy in Ontario, Canada, since 1991. METHODS: A medical chart review was conducted at 33 hospitals that were identified as having conducted at least one prophylactic mastectomy. All bilateral mastectomy patients with no diagnosis of invasive or in situ breast carcinoma were eligible. RESULTS: The number of prophylactic bilateral mastectomies performed varied from 6 to 19. The mean age of women undergoing prophylactic mastectomy was 43.5 years. Eighty percent of the women had prophylactic mastectomy performed because of a family history of breast carcinoma (89 of 99) or because of a known BRCA1 or BRCA2 mutation (10 of 99). Twenty percent of the women had no family history, but had the surgery for other benign breast conditions. Women with a family history of breast carcinoma were much more likely to have a total mastectomy (89%) than a subcutaneous mastectomy (11%). Sixty percent of the women had reconstructive surgery following mastectomy. CONCLUSIONS: Prophylactic mastectomy is not performed on a large scale. The introduction of genetic testing for BRCA1 and BRCA2 has the potential to change the patterns of practice for prophylactic mastectomy.

Adult↗

PubMed2002

The effect of a hepatitis serology testing algorithm on laboratory utilization.

RATIONALE, AIMS AND OBJECTIVES: Laboratory testing algorithms use patient and laboratory data to identify the optimal testing strategy for patients. Studies have shown that these algorithms can decrease test utilization. Since over-utilization of hepatitis serological tests was suspected, a hepatitis serology testing algorithm was initiated in Ontario, Canada. This study determined the effects of this algorithm on utilization. METHODS: Population-based retrospective observational study, involving all patients having viral hepatitis serological testing at private laboratories in Ontario, Canada, between July 1991 and December 1999. Prior to the testing algorithm, physicians listed the required specific antigens and antibodies on the test requisition form. In September 1996, the form was changed so that physicians identified the clinical indication--acute hepatitis, chronic hepatitis or immune status testing--for hepatitis serology testing. Therefore, the algorithm introduced a new 'tick-box' to the requisition form. Tests conducted by the laboratory depended upon which indication was chosen. Rates for hepatitis serological testing were calculated using population-based claims data. RESULTS: Time-series modelling showed that the testing algorithm was associated with a slight but significant increase in the use of hepatitis serology (P < 0.05). The algorithm was associated with an increase of 30 serological tests per 100,000 population per month. CONCLUSIONS: Introducing a testing algorithm for hepatic viral serology in Ontario did not significantly decrease hepatitis serology utilization and may be associated with a slight, but significant, increase in serology utilization rates.

Algorithms↗

PubMed2002

Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study.

OBJECTIVES: Infections with group A streptococcus (GAS) occur in 10% to 20% of patients with sore throats, whereas antibiotics are prescribed 50% of the time. Clinical scoring rules can more accurately predict the likelihood of GAS infection, but whether family physicians will adopt such approaches is unclear. This study sought to determine whether repeated clinical prompts to use a scoring approach could help family physicians lower antibiotic use in patients with a sore throat. STUDY DESIGN: Randomized trial in which physicians were assigned to use either (1) chart stickers that prompted them to calculate a score based on clinical findings and provided management recommendations linked to score totals or (2) a clinical checklist. POPULATION: Ninety-seven family physicians in Ontario, Canada, assessed 621 children and adults with sore throat and obtained a throat swab for culture. OUTCOMES MEASURED: (1) Unnecessary antibiotic prescriptions given to patients with a negative throat culture and (2) overall antibiotic use. RESULTS: There were no differences between the control and intervention group in unnecessary antibiotic prescriptions (16.1% vs 20.4%, respectively, P =.29) or overall antibiotic use (27.9% vs 28.1%, P =.97). However, a number of physicians dropped out of the study; as a result, the characteristics of the physicians in the 2 groups were dissimilar in factors related to prescribing. After adjusting for these differences and patient clustering by physician, the odds ratio for the effect of the intervention on unnecessary antibiotic prescriptions was 0.76 (95% confidence interval [CI] = 0.42, 1.40) and 0.57 for overall antibiotic use (95% CI = 0.27, 1.17). CONCLUSIONS: Chart prompts during clinical encounters to use a clinical score in the assessment of patients with a sore throat did not reduce unnecessary antibiotic prescribing by family physicians. The problems encountered in conducting this community-based intervention trial are discussed in relation to the negative result.

Adult↗

PubMed2002

What influences family physicians' cancer screening decisions when practice guidelines are unclear or conflicting?

OBJECTIVES: To determine (a) the respondents' perceptions of 4 unclear or conflicting cancer screening guidelines: prostate-specific antigen (PSA) for men over 50, mammography for women 40-49, colorectal screening by fecal occult blood testing (FOBT), and colonoscopy for patients over 40; and (b) the influence of various factors on the decision to order these tests. STUDY DESIGN: National Canadian mail survey of randomly selected family physicians. POPULATION: Family physicians in active practice (n=565) selected from rural and urban family medicine sites in 5 provinces representing the main regions in Canada. OUTCOME MEASURED: Agreement with guideline statements, and decision to order screening test in 6 clinical vignettes. RESULTS: Of 565 surveys mailed, 351 (62.1%) were returned. Most respondents agreed with the Canadian Task Force recommendations, and most believed that various guidelines for 3 of the 4 screens were conflicting (PSA 86.6%; mammography 67.5%; FOBT 62.4%). Patient anxiety about cancer, patient expectations of being tested, and a positive family history of cancer increased the odds that the 4 tests would be ordered. A good quality patient-MD relationship decreased the odds of ordering a mammogram. Screening decisions were also significantly influenced by the respondents' beliefs about whether screening was recommended and whether screening could cause more harm than good. A physician's sensitivity to his or her colleagues' practice influenced screening decisions regarding PSA and mammography. CONCLUSIONS: These results suggest a conceptual framework for understanding the determinants of screening behavior when guidelines are unclear or conflicting.

Adult↗

PubMed1999

Pilot study of an information aid for women with a family history of breast cancer.

OBJECTIVE: To develop and pilot study an information aid for women with a family history of breast cancer. DESIGN, SETTING AND PARTICIPANTS: The information aid, consisting of a booklet and audiotape, was developed by a multi-disciplinary team of health care professionals, breast cancer survivors and their relatives. Women with no personal history of breast cancer, on the waiting list for a familial breast cancer clinic at either of two centres, who could read English, were eligible for the pilot study which consisted of three sets of mailed questionnaires. MAIN OUTCOME MEASURES: The baseline questionnaires included: demographic information: the Breast Cancer and Heredity Knowledge Scale (BCHK); psychological measures (the State-Trait Anxiety Inventory [STAI], Centre for Epidemiologic Studies Depression Scale [CES-D] and an item about breast cancer worry), and an item about breast cancer risk perception. Immediately after reviewing the information aid, participants completed a satisfaction survey, the risk perception and cancer worry items and a checklist about their personal family history. The third set of questionnaires, completed 2-4 weeks after reviewing the aid, was identical to the first. Patients then attended their scheduled clinic visit and an objective hereditary breast cancer risk assessment was made by the genetic counselling team. RESULTS AND CONCLUSIONS: Of 97 eligible women who were contacted, 67 completed all three sets of questionnaires. Overall, women were very satisfied with the aid and 96% would recommend it to other women. There was a highly significant improvement in their knowledge scores after they reviewed the aid. Anxiety and depression did not change and there was a decline in breast cancer worry. Risk perception did not change significantly. Ninety per cent of women completed their personal family history checklist accurately. Several important improvements have been made in the information aid and it will now be evaluated in the community.

Journal Article↗

PubMed1999

Canadian family physicians and prostate cancer: a national survey.

A sample of family physicians was randomly selected from the membership database of the College of Family Physicians of Canada (CFPC). Potential respondents were mailed a survey questionnaire, and a modified Dillman approach was utilized. A total of 964 completed questionnaires were received, providing a response rate of 50.1%. Although most family physicians were aware of many basic facts about prostate cancer, there were knowledge limitations related to risk factors, relative frequency of the disease (to other cancers), and selected aspects of PSA effectiveness. There was considerable variation in perceived effectiveness of early detection methods, with most physicians taking a conservative approach to PSA utilization. Most family physicians indicated that they have an important role to play in the care of men after they have been diagnosed with prostate cancer. They also expressed a high level of interest in obtaining additional information related to prostate cancer.

Journal Article↗