Internet versus mailed questionnaires: a controlled comparison (2)

Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review

OBJECTIVE

Delphi technique is a structured process commonly used to developed healthcare quality indicators, but there is a little recommendation for researchers who wish to use it. This study aimed 1) to describe reporting of the Delphi method to develop quality indicators, 2) to discuss specific methodological skills for quality indicators selection 3) to give guidance about this practice.

METHODOLOGY AND MAIN FINDING

Three electronic data bases were searched over a 30 years period (1978-2009). All articles that used the Delphi method to select quality indicators were identified. A standardized data extraction form was developed. Four domains (questionnaire preparation, expert panel, progress of the survey and Delphi results) were assessed. Of 80 included studies, quality of reporting varied significantly between items (9% for year's number of experience of the experts to 98% for the type of Delphi used). Reporting of methodological aspects needed to evaluate the reliability of the survey was insufficient: only 39% (31/80) of studies reported response rates for all rounds, 60% (48/80) that feedback was given between rounds, 77% (62/80) the method used to achieve consensus and 57% (48/80) listed quality indicators selected at the end of the survey. A modified Delphi procedure was used in 49/78 (63%) with a physical meeting of the panel members, usually between Delphi rounds. Median number of panel members was 17(Q1:11; Q3:31). In 40/70 (57%) studies, the panel included multiple stakeholders, who were healthcare professionals in 95% (38/40) of cases. Among 75 studies describing criteria to select quality indicators, 28 (37%) used validity and 17(23%) feasibility.

CONCLUSION

The use and reporting of the Delphi method for quality indicators selection need to be improved. We provide some guidance to the investigators to improve the using and reporting of the method in future surveys.

Can the Toronto Extremity Salvage Score produce reliable results when used online?

BACKGROUND

Web-based questionnaires have become popular, however, access to the Internet can be biased regarding age, gender, and education, among other factors. Therefore, it is unknown whether this is a reasonable avenue to administer a questionnaire to patients or whether Web-based can be a reliable alternative to paper-based.

QUESTIONS/PURPOSES

We determined whether the Internet version of the Toronto Extremity Salvage Score is reproducible compared with the paper-based version and the compliance and completion rates.

PATIENTS AND METHODS

The study population consisted of 81 adults who had had surgery for a musculoskeletal tumor of the lower extremity more than 12 months earlier. The Toronto Extremity Salvage Score was administered by paper at a baseline interview and then readministered via Internet 7 to 14 days later to those with access.

RESULTS

Sixty of the 81 patients (74%) were able to use the Internet. Increasing age and lower education levels were correlated with a lower likelihood of using the Internet. Questionnaires were done online and on paper by 56 patients but 10 were excluded because of self-reported change in circumstances. The mean TESS was 85.7 (range, 41.1-100; SD, 17.26) for the paper-based questionnaire and 85.2 (range, 42.5-100; SD, 17.47) for the Internet-based questionnaire. The intraclass correlation coefficient was 0.97.

CONCLUSIONS

The questionnaire can be transferred successfully to the Internet and can be used reliably instead of a paper-based instrument. Recruitment to use an Internet-based questionnaire is limited only by the percentage of patients able to access and use the Internet.

Preparing for severe contrast media reactions in children - results of a national survey, a literature review and a suggested protocol

AIM

To identify current practices within paediatric radiology in the UK with regard to the use of prophylactic medication, prior to administering intravenous (IV) radiocontrast medium (RCM). In addition, the pre-injection risk management strategies of the departments questioned was to be evaluated, and using consensus opinion, a protocol for managing patients identified as being at high risk for an adverse reaction to RCM was to be outlined.

MATERIALS AND METHODS

An online survey of paediatric radiology consultants representing all geographic regions of the UK was carried out. The questions asked included an assessment of the risk factors for adverse reactions to RCM, and how such reactions are anticipated and managed. The questionnaire asked about the perceived indications for, and the use of prophylactic medication prior to RCM administration.

RESULTS

A response rate of 51% was achieved. The majority of respondents felt that a history of previous RCM reaction was an indication to administer prophylactic drugs prior to a further dose of RCM. No other risk factor was believed to require prophylactic medication.

CONCLUSION

Using information obtained from the survey, a literature search was performed to assess the evidence available in support of each practice. A protocol was devised to identify children at risk of an adverse reaction to RCM, and guide the use of prophylactic medication in this group of patients. The survey highlighted considerable variability in the risk-assessment and management practices within paediatric radiology in the UK. The derived protocol may guide radiologists' management of children at risk for an RCM reaction.

Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey

INTRODUCTION

Anemia is associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). It remains unclear whether this association can be modified with more aggressive use of red blood cell (RBC) transfusions. The degree to which restrictive thresholds have been adopted in neurocritical care patients remains unknown.

METHODS

We performed a survey of North American academic neurointensivists, vascular neurosurgeons and multidisciplinary intensivists who regularly care for patients with SAH to determine hemoglobin (Hb) concentrations which commonly trigger a decision to initiate transfusion. We also assessed minimum and maximum acceptable Hb goals in the context of a clinical trial and how decision-making is influenced by advanced neurological monitoring, clinician characteristics and patient-specific factors.

RESULTS

The survey was sent to 531 clinicians, of whom 282 (53%) responded. In a hypothetical patient with high-grade SAH (WFNS 4), the mean Hb concentration at which clinicians administered RBCs was 8.19 g/dL (95% CI, 8.07 to 8.30 g/dL). Transfusion practices were comparatively more restrictive in patients with low-grade SAH (mean Hb 7.85 g/dL (95% CI, 7.73 to 7.97 g/dL)) (P < 0.0001) and more liberal in patients with delayed cerebral ischemia (DCI) (mean Hb 8.58 g/dL (95% CI, 8.45 to 8.72 g/dL)) (P < 0.0001). In each setting, there was a broad range of opinions. The majority of respondents expressed a willingness to study a restrictive threshold of ≤8 g/dL (92%) and a liberal goal of ≥10 g/dl (75%); in both cases, the preferred transfusion thresholds were significantly higher for patients with DCI (P < 0.0001). Neurosurgeons expressed higher minimum Hb goals than intensivists, especially for patients with high-grade SAH (β = 0.46, P = 0.003), and were more likely to administer two rather than one unit of RBCs (56% vs. 19%; P < 0.0001). Institutional use of transfusion protocols was associated with more restrictive practices. More senior clinicians preferred higher Hb goals in the context of a clinical trial. Respondents were more likely to transfuse patients with brain tissue oxygen tension values <15 mmHg and lactate-to-pyruvate ratios >40.

CONCLUSIONS

There is widespread variation in the use of RBC transfusions in SAH patients. Practices are heavily influenced by the specific dynamic clinical characteristics of patients and may be further modified by clinician specialty and seniority, the use of protocols and advanced neurological monitoring.

Use of a web-based questionnaire in the Black Women's Health Study

The authors assessed the utility and cost-effectiveness of using a World Wide Web-based questionnaire in a large prospective cohort study, the Black Women's Health Study (BWHS). In 1995, 59,000 African-American women were recruited into the BWHS through a paper questionnaire. Follow-up paper questionnaires have been mailed every 2 years since then. During the 2003, 2005, and 2007 questionnaire cycles, participants were given the option of completing a Web-based questionnaire. The cost of developing and processing a returned paper questionnaire was 4 times that of a returned Web questionnaire, primarily because of return postage costs and greater processing time for paper questionnaires. The proportion of respondents who completed a Web questionnaire doubled from 2003 to 2007, from 10.1% to 19.9%, but the characteristics of those completing the Web questionnaire remained the same. Web response was greatest at younger ages (20.9% of those aged <30 years) and declined with age to 3.6% among women aged 60 years or more. Web questionnaires were filled out more completely than paper questionnaires, regardless of the sensitivity of a question. The use of a Web questionnaire in the BWHS resulted in cost savings and more complete responses. Although there are advantages to using a Web questionnaire, the use of multiple means of soliciting questionnaire responses is still needed.

Barriers to implementing evidence-based clinical guidelines: a survey of early adopters

OBJECTIVE

The purpose of this study was to identify barriers that early-adopting dentists perceive as common and challenging when implementing recommendations from evidence-based (EB) clinical guidelines.

METHOD

This is a cross-sectional study. Dentists who attended the 2008 Evidence-based Dentistry Champion Conference were eligible for inclusion. Forty-three dentists (34%) responded to a 22-item questionnaire administered online. Two investigators independently coded and categorized responses to open-ended items. Descriptive statistics were computed to assess the frequency of barriers and perceived challenges.

RESULTS

The most common barriers to implementation were difficulty in changing current practice model, resistance and criticism from colleagues, and lack of trust in evidence or research. Barriers perceived as serious problems had to do with lack of up-to-date evidence, lack of clear answers to clinical questions, and contradictory information in the scientific literature.

CONCLUSIONS

Knowledge of barriers will help improve translation of biomedical research for dentists. Information in guidelines needs to be current, clear, and simplified for use at chairside; dentists' fears need to be addressed.

The influence of response mode on study results: offering cigarette smokers a choice of postal or online completion of a survey

BACKGROUND

It is unclear whether offering online data collection to study participants affects compliance or produces bias.

OBJECTIVE

To compare response rates, baseline characteristics, test-retest reliability, and outcomes between cigarette smokers who chose to complete a survey by mail versus those who chose to complete it online.

METHODS

We surveyed cigarette smokers who intended to stop smoking within the next 30 days to determine barriers to calling a smoking quit line. Participants were offered the choice of completing a paper version of the survey sent through the mail or an online version at a password-protected website. Participants were called 2 months later to determine if they had made a quit attempt and/or called a smoking quit line since the baseline survey. We compared characteristics and outcomes among those who chose postal versus online completion. We measured test-retest reliability of the baseline survey by re-surveying a semi-random sample of participants within 10 days of the original survey.

RESULTS

Of 697 eligible respondents to newspaper ads in 12 US cities, 438 (63%) chose to receive a mailed paper survey and 259 (37%) chose an Internet survey. Survey return rates were the same for the 2 modes (92% versus 92%, P = .82). Online respondents were younger (mean of 46 versus 51 years old for postal, P < .001), more likely to be white (76% versus 62%, P < .001), less likely to be African American (18% versus 30%, P < .001), more highly educated (34% college graduate versus 23%, P < .001), more likely to intend to stop smoking in the next 30 days (47% definitely versus 30%, P < .001), and more likely to have heard of a smoking quit line (51% versus 40%, P = .008). Participants did not differ on gender (54% female for online versus 55% for postal, P = .72) or cigarettes smoked per day (mean of 19 versus 21, P = .30). Online respondents had slightly fewer missing items on the 79-item survey (mean of 1.7% missing versus 2.3%, P = .02). Loss to follow-up at 2 months was similar (16% for online and 15% for postal, P = .74). There was no significant difference between online and postal respondents in having called a smoking quit line during the 2-month follow-up period (20% versus 24%, P = .22) or in having made a quit attempt (76% versus 79%, P = .41).

CONCLUSIONS

Cigarette smokers who chose to complete a survey using the Internet differed in several ways from those who chose mailed surveys. However, more importantly, online and postal responses produced similar outcomes.

A within-subjects trial to test the equivalence of online and paper outcome measures: the Roland Morris disability questionnaire

BACKGROUND

Augmenting validated paper versions of existing outcome measures with an equivalent online version may offer substantial research advantages (cost, rapidity and reliability). However, equivalence of online and paper questionnaires cannot be assumed, nor can acceptability to respondents. The aim was to test whether online and written versions of the Roland Morris Disability Questionnaire (RMDQ), a standard measure of functional disability in back pain, are equivalent at both group and individual levels to establish whether they can be used interchangeably.

METHODS

This is a within-participants equivalence study. 167 participants with back pain fully completed both the paper and online versions of the RMDQ in random order. Participants were recruited from a chiropractic clinic and patient support groups in Southern England. Limits of equivalence were pre-defined as 0.5 RMDQ points, the Bland-Altman range was calculated, and participants' comments were examined using content analysis.

RESULTS

The mean score difference was 0.03 (SD = 1.43), with the 95% Confidence Interval falling entirely within our limits of equivalence (-0.19 to 0.25). The Bland-Altman range was -2.77 to 2.83 RMDQ points. Participants identified unique advantages and disadvantages associated with each version of the RMDQ.

CONCLUSIONS

The group and individual level data suggest that online and paper versions of the RMDQ are equivalent and can be used interchangeably. The Bland-Altman range appears to reflect the known measurement properties of the RMDQ. Furthermore, participants' comments confirmed the potential value to be had from offering them the choice of completing the RMDQ online or on paper.

Motivations, job procurement, and job satisfaction among current and former ultrasound fellows

OBJECTIVES

Over the past decade, emergency medicine ultrasound (US) fellowships have proliferated, yet there are no published data describing employment trends among fellowship graduates. This study sought to assess factors motivating emergency physicians to pursue an US fellowship and to characterize their employment and job satisfaction after graduation.

METHODS

An electronic survey was conducted of US fellows and graduates representing all 35 known fellowship programs. Non-responders were contacted at 2 weeks to encourage participation. Primary outcome measurements were the importance of factors motivating individuals to pursue an US fellowship (as rated on a numeric scale), job satisfaction among US fellowship graduates, the proportion of respondents practicing in academic versus community hospitals, clinical hours per week, and the rate of procurement of one's top choice of job after graduation. The chi-square test or Fisher's exact test was used for categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between two groups.

RESULTS

Of 170 invitations sent, 10 were undeliverable. The response rate was 61%; 74 graduates and 23 fellows completed the survey. Enhancing job opportunities, enjoyment of US, long-term job satisfaction and gaining skills not learned in residency rated highest as reasons for pursuing an US fellowship. Among graduates, 20% are satisfied with their current job, while 78% are very satisfied or extremely satisfied. Nearly one-third of graduates (31%) work primarily in non-academic hospitals, while only 9% of current fellows aspire to work in non-academic settings in the future. There was no difference in job satisfaction between academic- and community-based graduates. In comparison to those graduating in previous years, fellows graduating in 2008 were less likely to get their top job (97% vs. 75.0%, p = 0.018).

CONCLUSIONS

Job satisfaction is high among US fellowship graduates and is unrelated to academic versus community affiliation. Three-fourths of recent graduates obtain their top choice of job upon completion of fellowship.

Updating systematic reviews: an international survey

Background

Systematic reviews (SRs) should be up to date to maintain their importance in informing healthcare policy and practice. However, little guidance is available about when and how to update SRs. Moreover, the updating policies and practices of organizations that commission or produce SRs are unclear.

Methodology/Principal Findings

The objective was to describe the updating practices and policies of agencies that sponsor or conduct SRs. An Internet-based survey was administered to a purposive non-random sample of 195 healthcare organizations within the international SR community. Survey results were analyzed using descriptive statistics. The completed response rate was 58% (n = 114) from across 26 countries with 70% (75/107) of participants identified as producers of SRs. Among responders, 79% (84/107) characterized the importance of updating as high or very-high and 57% (60/106) of organizations reported to have a formal policy for updating. However, only 29% (35/106) of organizations made reference to a written policy document. Several groups (62/105; 59%) reported updating practices as irregular, and over half (53/103) of organizational respondents estimated that more than 50% of their respective SRs were likely out of date. Authors of the original SR (42/106; 40%) were most often deemed responsible for ensuring SRs were current. Barriers to updating included resource constraints, reviewer motivation, lack of academic credit, and limited publishing formats. Most respondents (70/100; 70%) indicated that they supported centralization of updating efforts across institutions or agencies. Furthermore, 84% (83/99) of respondents indicated they favoured the development of a central registry of SRs, analogous to efforts within the clinical trials community.

Conclusions/Significance

Most organizations that sponsor and/or carry out SRs consider updating important. Despite this recognition, updating practices are not regular, and many organizations lack a formal written policy for updating SRs. This research marks the first baseline data available on updating from an organizational perspective.

Prioritization strategies in clinical practice guidelines development: a pilot study

OBJECTIVE

Few methodological studies address the prioritization of clinical topics for the development of Clinical Practice Guidelines (CPGs). The aim of this study was to validate a methodology for Priority Determination of Topics (PDT) of CPGs.

METHODS AND RESULTS

Firstly, we developed an instrument for PDT with 41 criteria that were grouped under 10 domains, based on a comprehensive systematic search. Secondly, we performed a survey of stakeholders involved in CPGs development, and end users of guidelines, using the instrument. Thirdly, a pilot testing of the PDT procedure was performed in order to choose 10 guideline topics among 34 proposed projects; using a multi-criteria analysis approach, we validated a mechanism that followed five stages: determination of the composition of groups, item/domain scoring, weights determination, quality of the information used to support judgments, and finally, topic selection. Participants first scored the importance of each domain, after which four different weighting procedures were calculated (including the survey results). The process of weighting was determined by correlating the data between them. We also reported the quality of evidence used for PDT. Finally, we provided a qualitative analysis of the process. The main domains used to support judgement, having higher quality scores and weightings, were feasibility, disease burden, implementation and information needs. Other important domains such as user preferences, adverse events, potential for health promotion, social effects, and economic impact had lower relevance for clinicians. Criteria for prioritization were mainly judged through professional experience, while good quality information was only used in 15% of cases.

CONCLUSION

The main advantages of the proposed methodology are supported by the use of a systematic approach to identify, score and weight guideline topics selection, limiting or exposing the influence of personal biases. However, the methodology was complex and included a number of quantitative and qualitative approaches reflecting the difficulties of the prioritization process.

Patient organisations and the reimbursement process for medicines: an exploratory study in eight European countries

BACKGROUND

Little is known about the role European patient organisations play in the process of deciding on reimbursement for medicines. Therefore we explore the current role of patient organisations in the process of reimbursement for medicines in Western Europe. We focus in particular on collaboration between patient organisations and the pharmaceutical industry in this respect.

METHODS

Sixty-eight patient organisations representing seven medical conditions, from ten Western European countries, were asked to participate in the study. The participating organisations reported their experiences in a web-based questionnaire.

RESULTS

Twenty-one patient organisations completed the questionnaire (response rate: 31%), of which ten (47.6%) demanded reimbursement for medicines. Organisations demanding reimbursement were larger than those not demanding reimbursement. The main aim of these organisations was to create better accessibility of medicines for patients. Most organisations limited themselves to single actions. Only two engaged in multiple actions. Almost all organisations had general policies on cooperation with the pharmaceutical industry, with autonomy as the key feature. The patient organisations said they were reasonably successful and almost always satisfied with their own role in the reimbursement process.

CONCLUSION

Our study has found that the role of European patient organisations in the reimbursement process still seems limited, especially for small patient organisations.

Nonsteroidal Anti-Inflammatory Drugs: A survey of practices and concerns of pediatric medical and surgical specialists and a summary of available safety data

OBJECTIVES

To examine the prescribing habits of NSAIDs among pediatric medical and surgical practitioners, and to examine concerns and barriers to their use.

METHODS

A sample of 1289 pediatricians, pediatric rheumatologists, sports medicine physicians, pediatric surgeons and pediatric orthopedic surgeons in the United States and Canada were sent an email link to a 22-question web-based survey.

RESULTS

338 surveys (28%) were completed, 84 were undeliverable. Of all respondents, 164 (50%) had never prescribed a selective cyclooxygenase-2 (COX-2) NSAID. The most common reasons for ever prescribing an NSAID were musculoskeletal pain, soft-tissue injury, fever, arthritis, fracture, and headache. Compared to traditional NSAIDs, selective COX-2 NSAIDs were believed to be as safe (42%) or safer (24%); have equal (52%) to greater efficacy (20%) for pain; have equal (59%) to greater efficacy (15%) for inflammation; and have equal (39%) to improved (44%) tolerability. Pediatric rheumatologists reported significantly more frequent abdominal pain (81% vs. 23%), epistaxis (13% vs. 2%), easy bruising (64% vs. 8%), headaches (21% vs. 1%) and fatigue (12% vs. 1%) for traditional NSAIDs than for selective COX-2 NSAIDs. Prescribing habits of NSAIDs have changed since the voluntary withdrawal of rofecoxib and valdecoxib; 3% of pediatric rheumatologists reported giving fewer traditional NSAID prescriptions, and while 57% reported giving fewer selective COX-2 NSAIDs, 26% reported that they no longer prescribed these medications.

CONCLUSIONS

Traditional and selective COX-2 NSAIDs were perceived as safe by pediatric specialists. The data were compared to the published pediatric safety literature.

Measurement of CPOE end-user satisfaction among ICU physicians and nurses

BACKGROUND: Implementation of Computerized Provider Order Entry (CPOE) can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by CPOE. End-user satisfaction is a critical factor in IT implementation. OBJECTIVE: The goal of this study was to identify criteria to select a valid and reliable questionnaire to measure end-user satisfaction with CPOE. METHODS: We developed seven criteria that can be used to select valid and reliable questionnaires. We applied the selection criteria to existing end-user satisfaction questionnaires. RESULTS: Most of the questionnaires used to measure end-user satisfaction have been tested for reliability and validity and most of the questionnaires have reasonably reliability and some sort of validity. However, only one questionnaire, the Physician Order Entry User Satisfaction and Usage Survey (POESUS) met most of the other criteria we developed to select a questionnaire to evaluate CPOE implementation. We used the POESUS in our study and compared the results with other studies. Results show that users are moderately satisfied with CPOE. CONCLUSION: Using the seven criteria we developed, it is possible to select reliable and valid questionnaires. We hope that in the future this will lead to an increasing number of studies using the same questionnaires. That will improve the possibilities for comparing the results of one study to another (benchmarking).

Willingness to volunteer during an influenza pandemic: perspectives from students and staff at a large Canadian university

Background  A future influenza pandemic will require greater demand on numerous essential services and a reduced capacity to meet that demand. Recruitment of volunteers is an important issue for pre‐pandemic planning.

Objectives  To identify factors and attitudes towards volunteerism in the event of a pandemic of influenza.

Participants/methods  A 42‐item web‐questionnaire was administered to all faculty, staff and students at the University of Alberta. Respondents indicated their willingness to volunteer. Responses were dichotomized and logistic regression models were developed to capture the association between willingness to volunteer and (i) demographic and information source variables, (ii) risk perception and general knowledge, and (iii) volunteering attitudes and priority access variables.

Results  Many factors predicted willingness to volunteer and several involved interactions with other variables. Individuals who were older, relied on University Health Centre information and who had past volunteerism experience were generally more likely to be willing to volunteer. Those willing to volunteer were more likely to think spread could be prevented by covering mouth when coughing/sneezing, and treatment would include drinking fluids. Those who thought influenza would be treated by antibiotics were less willing to volunteer. Likely volunteers thought that healthcare students should be encouraged to volunteer if there was a healthcare worker shortage.

Conclusion  This study provides guidance for those who are preparing universities to deal with pandemic influenza. The results suggest factors that might be important in the recruitment of volunteers during an influenza pandemic and these factors might be relevant for other sectors as well.

Survey design in orthopaedic surgery: getting surgeons to respond

We provide an overview of survey design and implementation strategies in orthopaedic surgery. Health-care surveys are vital for obtaining information on the beliefs, patterns of practice, attitudes, and behaviors of orthopaedic surgeons. It is important to obtain a high response rate from administered surveys to reduce bias due to nonresponse. Researchers should follow the guidelines provided by this review to increase the response rate of orthopaedic surgeons to surveys. When designing these surveys, the researcher must consider length, format, and aesthetics. In addition, the types of questions that are included, the wording of these questions, and the order in which the questions are presented within the survey need to be carefully considered. Surveys can be administered by telephone, mail, facsimile (fax), and electronically by e-mail or Internet. The use of a mixed-mode method is recommended to improve the response rate. To increase the response rate to surveys that are directed at health professionals, a number of strategies have been suggested, including using cover letters, personalizing the cover letter and survey package, pretesting the cover letter and survey, contacting the surgeons prior to administration of the survey, contacting the surgeons multiple times, using stamped return envelopes in mail surveys, using appropriate survey packaging styles, providing incentives, and ensuring that the orthopaedic surgeon recognizes the sender of the survey. The costs associated with each administration method are briefly discussed, and ethical considerations are reviewed.

Use of web and in-person survey modes to gather data from young adults on sex and drug use: an evaluation of cost, time, and survey error based on a randomized mixed-mode design

In a randomized test of mixed-mode data collection strategies, 386 participants in the Raising Healthy Children (RHC) Project were either (a) asked to complete a survey via the Internet and later offered the opportunity to complete the survey in person or (b) first offered an in-person survey, with the Web follow-up. The Web-first condition resulted in cost savings although the overall completion rates for the 2 conditions were similar. On average, in-person-first condition participants completed surveys earlier in the field period than Web-first condition participants. Based on intent-to-treat analyses, little evidence of condition effects on response bias, with respect to rates or levels of reported behavior, was found.

Urinary tract infections in children with spina bifida: an inventory of 41 European centers

The introduction of clean intermittent catheterization (CIC) in 1972 and low-dose chemoprophylaxis (LDCP, antibiotic prophylaxis), anticholinergic medication and urological surgery in the mid-1980s has improved the long-term outcome of renal function in children with neurogenic bladder sphincter dysfunction (NBSD) due to spina bifida (SB). We have conducted a European survey of the protocols for diagnosing and treating urinary tract infections (UTIs) in these children, using a web-based questionnaire. The responses from 41 centers in 14 European countries confirm that although most centers have standardized protocols for treating UTIs, there is no consensus among European centers in terms of protocols for preventing, diagnosing and treating UTIs in children with NBSD and for CIC.

A comparison of Canadian pediatric resident career plans in 1998 and 2006

OBJECTIVES

Studies of pediatric resident career plans and preferences help to forecast changes in the demographic profile and practice patterns of North American pediatricians, providing insights that can guide child health care and medical education policy making. With this study we aimed to compare 4 aspects of Canadian pediatric resident career plans in 1998 and 2006: (1) weekly work hours; (2) scope of practice; (3) professional activities; and (4) community size.

METHODS

Canadian pediatric residents were invited to participate in a national cross-sectional survey to explore career plans and preferences in 1998 (mailing) and 2006 (on-line).

RESULTS

Response rates were 69% in 1998 and 52% in 2006. In both survey years, the majority of respondents were female (69% and 73%, respectively). Overall, residents planned to work a similar number of weekly hours in both survey years (47.8 vs 48.8). Women planned to work significantly fewer hours than men; this gap was wider in 2006 than in 1998 (1998: 2.8 fewer hours; 2006: 7.8 fewer hours). After adjusted analysis, the association between proportion of time in primary care and study year became significant; however, time in consultant general or subspecialty pediatrics remained nonsignificantly changed. Residents planned to spend less time in clinical work in 2006 than 1998 (64.4% vs 58.1%), and more planned to work and reside in metropolitan areas (68% vs 78% of decided respondents).

CONCLUSIONS

Between 1998 and 2006, there was no overall change in the number of hours that Canadian pediatric residents planned to work, but the gender gap widened because of an increase in planned weekly work hours among men. The results also suggest that new strategies may be needed to improve future pediatrician availability in small communities by addressing barriers to nonmetropolitan practice, especially for women.

Response audit of an Internet survey of health care providers and administrators: implications for determination of response rates

Background

Internet survey modalities often compare unfavorably with traditional survey modalities, particularly with respect to response rates. Response to Internet surveys can be affected by the distribution options and response/collection features employed as well as the existence of automated (out-of-office) replies, automated forwarding, server rejection, and organizational or personal spam filters. However, Internet surveys also provide unparalleled opportunities to track study subjects and examine many of the factors influencing the determination of response rates. Tracking data available for Internet surveys provide detailed information and immediate feedback on a significant component of response that other survey modalities cannot match. This paper presents a response audit of a large Internet survey of more than 5000 cancer care providers and administrators in Ontario, Canada.

Objective

Building upon the CHEcklist for Reporting Results of Internet E-Surveys (CHERRIES), the main objectives of the paper are to (a) assess the impact of a range of factors on the determination of response rates for Internet surveys and (b) recommend steps for improving published descriptions of Internet survey methods.

Methods

We audited the survey response data, analyzing the factors that affected the numerator and denominator in the ultimate determination of response. We also conducted a sensitivity analysis to account for the inherent uncertainty associated with the impact of some of the factors on the response rates.

Results

The survey was initially sent out to 5636 health care providers and administrators. The determination of the numerator was influenced by duplicate/unattached responses and response completeness. The numerator varied from a maximum of 2031 crude (unadjusted) responses to 1849 unique views, 1769 participants, and 1616 complete responses. The determination of the denominator was influenced by forwarding of the invitation email to unknown individuals, server rejections, automated replies, spam filters, and ‘opt out’ options. Based on these factors, the denominator varied from a minimum of 5106 to a maximum of 5922. Considering the different assumptions for the numerator and the denominator, the sensitivity analysis resulted in a 12.5% variation in the response rate (from minimum of 27.3% to maximum of 39.8%) with a best estimate of 32.8%.

Conclusions

Depending on how the numerator and denominator are chosen, the resulting response rates can vary widely. The CHERRIES statement was an important advance in identifying key characteristics of Internet surveys that can influence response rates. This response audit suggests the need to further clarify some of these factors when reporting on Internet surveys for health care providers and administrators, particularly when using commercially available Internet survey packages for specified, rather than convenience, samples.

A very low response rate in an on-line survey of medical practitioners

OBJECTIVE

To report on the response rate achieved in a survey of medical practitioners and discuss the reasons for it.

METHOD

An on-line (internet-based) survey of all 609 registered pharmacotherapy prescribers in Victoria and Queensland; invitations to participate were sent by mail in late April 2007, and one reminder letter in late May 2007.

RESULTS

Six hundred and nine invitation letters were mailed, nine were returned to sender, and 52 questionnaires completed, making the overall response rate 52/600 = 8.7%. The response rate in Queensland was 13.2% (16/121), and in Victoria 7.5% (36/479).

CONCLUSIONS

Despite utilising sound techniques, our response rate was much lower than those achieved in recent Australian paper-based surveys of medical practitioners. It is possible that the issue being addressed (injecting-related injuries and diseases) was not of high priority for many invitees, leading to reduced response.

IMPLICATIONS

On-line surveys are not yet an effective method of collecting data from Australian medical practitioners; researchers should continue to use paper questionnaires for maximum response.

Application of novel communication technologies to the study of farm families: a randomized controlled trial

OBJECTIVE

The objective of this pilot study was to evaluate the efficacy of three different communication technologies for collection of health outcomes from farm households.

METHODS

A randomized controlled trial was conducted in central Saskatchewan, Canada in 2006. The 94 farms completing the baseline questionnaire were randomly assigned to follow-up by regular mail (n=30), computer telephony (n=32), or their choice of regular mail, computer telephony, or e-mail follow-up (n=32). The primary endpoints were absolute differences in the proportions of farms using the assigned method to provide follow-up data, 2 months post-recruitment.

RESULTS

Of the total study population, 51 (54.3%) provided follow-up information. Farms in the regular mail arm were more likely to submit follow-up data than farms in the other arms (27/30 regular mail vs. 23/32 choice vs. 2/32 computer telephony). The differences in proportions between the computer telephony and other study arms were highly significant (e.g., absolute difference between regular mail and computer telephony 83.7% [95% CI: 70.1%, 97.3%; p<0.001]).

CONCLUSION

The optimal method for health outcome data collection from farm households in our study is regular mail. Despite their novelty and attractiveness, caution is warranted when adopting modern communication technologies in population health research.

Opinions on registering trial details: a survey of academic researchers

Background

The World Health Organization (WHO) has established a set of items related to study design and administrative information that should build the minimum set of data in a study register. A more comprehensive data set for registration is currently developed by the Ottawa Group. Since nothing is known about the attitudes of academic researchers towards prospective study registration, we surveyed academic researchers about their opinion regarding the registration of study details proposed by the WHO and the Ottawa Group.

Methods

This was a web-based survey of academic researchers currently running an investigator-initiated clinical study which is registered with clinicaltrials.gov. In July 2006 we contacted 1299 principal investigators of clinical studies by e-mail explaining the purpose of the survey and a link to access a 52-item questionnaire based on the proposed minimum data set by the Ottawa Group. Two reminder e-mails were sent each two weeks apart. Association between willingness to disclose study details and study phase was assessed using the chi-squared test for trend. To explore the potential influence of non-response bias we used logistic regression to assess associations between factors associated with non-response and the willingness to register study details.

Results

Overall response was low as only 282/1299 (22%) principal investigators participated in the survey. Disclosing study documents, in particular the study protocol and financial agreements, was found to be most problematic with only 31% of respondents willing to disclose these publicly. Consequently, only 34/282 (12%) agreed to disclose all details proposed by the Ottawa Group. Logistic regression indicated no association between characteristics of non-responders and willingness to disclose details.

Conclusion

Principal investigators of non-industry sponsored studies are reluctant to disclose all data items proposed by the Ottawa Group. Disclosing the study protocol and financial agreements was found to be most problematic. Future discussions on trial registration should not only focus on industry but also on academic researchers.

Methodologies for improving response rates in surveys of physicians: a systematic review

Although physician surveys are an important tool in health services and policy research, they are often characterized by low response rates. The authors conducted a systematic review of 66 published reports of efforts to improve response rates to physician surveys. Two general strategies were explored in this literature: incentive and design-based approaches. Even small financial incentives were found to be effective in improving physician response. Token nonmonetary incentives were much less effective. In terms of design strategies, postal and telephone strategies have generally been more successful than have fax or Web-based approaches, with evidence also supporting use of mixed-mode surveys in this population. In addition, use of first-class stamps on return envelopes and questionnaires designed to be brief, personalized, and endorsed by legitimizing professional associations were also more likely to be successful. Researchers should continue to implement design strategies that have been documented to improve the survey response of physicians.

Methodological and ethical issues in Internet-mediated research in the field of health: An integrated review of the literature

The advantages and disadvantages of using the Internet in both qualitative and quantitative researches in the field of health are readily available in the literature, but little examination has been made of the factors to be considered in developing and running Internet-mediated research. A bibliographic search of English language publications indexed in eight computerized databases (EBSCO, EMBASE, MedLine, PsycInfo, CINAHL, PubMed, Cochrane, and TRIP) was undertaken with no limit set for the data of publication. The keywords Internet, research, quality, credibility, reliability, and validity were used in all possible combinations, and mappings to headings made wherever possible. The search revealed three key areas in setting up and undertaking Internet-mediated research: addressing sampling biases, ensuring ethical practice, and exploring the validity of data collected using an online interface. This paper contributes to the ongoing development of quality standards in the conduct and write-up of Internet-mediated research in the field of health.

Parents' attitudes towards hepatitis B vaccination for their children. A survey comparing paper and web questionnaires, Sweden 2005

Background

The World Health Organisation, WHO, recommends that most countries should vaccinate all children against hepatitis B. Sweden has chosen not to do so, but the issue is reassessed regularly. The objective of this survey was to assess knowledge and attitudes towards hepatitis B vaccine for children among parents living in Sweden, and to compare distribution of responses and response rate between parents answering a postal questionnaire and those responding via the Internet.

Methods

A population-based cross-sectional survey, where the sampling frame consisted of all parents to a child born 2002 living in Sweden. Two independent samples of 1001 parents in each sample were drawn. All parents were contacted by postal mail. The parents in the first sample were invited to participate by answering a paper questionnaire. The parents in the second sample were given an individual user name along with a password, and asked to log on to the Internet to answer an identical electronic questionnaire.

Results

A total of 1229 questionnaires were analysed. The overall response rate for paper questionnaires was 55%, and 15% for the web version. Knowledge of the disease hepatitis B was overall high (90%). A higher degree of knowledge was seen among parents with education beyond high school (p = 0.001). This group of parents also had a higher tendency to reply via the Internet (p = 0.001). The willingness to accept hepatitis B vaccine for their child was correlated to the acceptance of the present childhood vaccination programme (p = 0.001).

Conclusion

The results reveal a high level of knowledge of the disease and a positive attitude to having their children vaccinated. This study also displays that the conventional postal method of surveying still delivers a higher response rate than a web-based survey.

The Fate of Epidemiologic Manuscripts

BACKGROUND

Little is known about the success rate of epidemiologic manuscripts, or the number of rejections they may go through before being published.

METHODS

In late 2004 we conducted a retrospective follow-up study of the cohort of manuscripts submitted to Epidemiology in 2002. Using an e-mailed invitation, we conducted an online survey of authors identified from journal records. Authors were asked about submission attempts before and after their submission to Epidemiology.

RESULTS

Epidemiology received 371 original articles in 2002, of which it published 101 (27%). Survey response rates were 68% among the authors of accepted manuscripts, and 58% among authors of manuscripts rejected by Epidemiology. These responses provided a total sample of 223 manuscripts for analysis. Of the cohort, 83% (n = 184) were eventually accepted for publication (by Epidemiology or others). The acceptance rate by Epidemiology was the same whether or not the manuscripts had been previously rejected by another journal. Of the 155 manuscripts rejected by Epidemiology, 116 (75%) were eventually published or accepted for publication, 11 (7%) were being prepared for resubmission at the time of follow-up (19-34 months after rejection), 5 (3%) were under review by a journal, and 23 (15%) were inactive. Among the papers we could follow from first submission, 62% of those eventually published had been rejected at least once. In general, papers rejected by one journal were subsequently sent to a journal with lower impact factor.

CONCLUSIONS

These data suggest most epidemiology manuscripts are eventually published, although some persistence on the part of the authors may be necessary.

Colorectal cancer screening perceptions and practices: results from a national survey of gastroenterology, surgery and radiology trainees

BACKGROUND

Colorectal cancer (CRC) screening in the United States is suboptimal. We conducted a national survey to learn about CRC screening perceptions and practices among trainees who perform CRC screening tests including those enrolled in Gastroenterology and Hepatology (GIH), General and Colorectal Surgery, and Diagnostic and Abdominal Radiology training programs.

METHODS

Program directors/administrators (PDs/PAs) from 642 programs were contacted by e-mail with an invitation to forward our survey to trainees in their programs. Participating trainees then completed an anonymous, Web-based questionnaire.

RESULTS

A total of 130/642 (20%) PDs/PAs forwarded our survey to their trainees, with responses received from 476 trainees (80 GIH, 261 surgery, 135 radiology). Colonoscopy was felt to be the best CRC screening test at reducing CRC mortality, with patient-related factors perceived as greater barriers than system-related factors. No single guideline was deemed very influential on CRC screening practices by most trainees. A total of 2 of 5 above-average risk patient profiles were not recognized by most trainees. Colonoscopy was selected as the preferred follow-up test for a positive CRC screening test by most trainees. However, 34% of respondents chose an option other than colonoscopy alone for follow-up of a positive fecal occult blood test.

CONCLUSIONS

Based on data from this national survey of gastroenterology, surgery, and radiology trainees, opportunities exist for curricular changes that may help enhance current perceptions and practices of trainees who perform CRC screening tests.

Clinical Registered Dietitians, Employers, and Educators Are Interested in Advanced Practice Education and Professional Doctorate Degrees in Clinical Nutrition

A subset of registered dietitians (RDs) is known to practice at an advanced level, but a clear educational pathway supporting advanced medical nutrition therapy practice has not been identified. Thus, an electronic survey was designed to investigate interest of clinical RDs, employers, and educators in advanced practice competencies and professional doctorate degree programs in clinical nutrition. Usable responses were obtained from 440 of 978 (45%) RDs, 61 of 107 (57%) employers, and 76 of 114 (67%) educators. Mean interest (5 = very interested, 1 = very uninterested) in obtaining advanced practice education was highest among RDs (3.93+/-1.01) and was significantly different (P < 0.01) from employers (3.74 +/-1.28) and educators (2.76+/-1.33). Interest in completing a professional doctorate in clinical nutrition was significantly (P < 0.01) different among RDs (3.05+/-1.28), employers (3.18+/-1.30), and educators (2.3+/-1.34). Employers' mean interest score for hiring RDs with a professional doctorate in clinical nutrition was 4.02+/-0.93. A subset of clinical RDs appears to be interested in obtaining advanced practice competency and enrolling in professional doctorate degrees in clinical nutrition. Clinical nutrition managers in academic medical centers may be interested in hiring advanced practice clinical RDs with professional doctorate degrees. Opportunities exist for educators to develop advanced practice educational experiences and professional doctorate degree programs.

The importance of colonoscopy in colorectal surgeons' practices: results of a survey

PURPOSE

The role of colonoscopy in the prevention of colorectal cancer has been accepted, not only by the medical community but by the federal government as well. This study sought to document the current role of colonoscopy in the practices of colorectal surgeons.

METHODS

A survey was mailed to members of The American Society of Colon and Rectal Surgeons detailing the scope of colonoscopy in their practices.

RESULTS

Surveys were mailed to 1,800 members of The American Society of Colon and Rectal Surgeons; responses were received from 778 (43.2 percent). The mean age was 48 +/- 10 (range, 27-79) years; the mean number of years in practice was 14 +/- 10 (range, 0.2-48). The majority of respondents (91 percent) were male. Responses were received from 47 U.S. states and 30 foreign countries. Seventy-four respondents (9.5 percent) reported not performing colonoscopy; the most common reason cited was "referring physicians' preference" (45 percent). Seven-hundred four respondents (90.5 percent) reported performing colonoscopy as part of their clinical practice and reported an average of 41 +/- 41 colonoscopies in the last month (range, 0-635) and 457 +/- 486 in the last year (range, 2-7,000). Colonoscopy accounted for 23 +/- 16 percent of responding physicians' clinical time (range, 1-100 percent) and 27 +/- 19 percent of total charges (range, 0-100 percent). Nearly all respondents (97 percent) anticipated maintaining or increasing their volume of colonoscopy in the coming year. Eighty-four percent of respondents reported receiving some or all of their training in colonoscopy during a colon and rectal surgery fellowship. More than one-half of respondents (55 percent) believed that there should be more of an emphasis on colonoscopy on the American Board of Colon and Rectal Surgery board examination, and 81 percent believed that the annual meeting of The American Society of Colon and Rectal Surgeons should include lectures and/or courses covering colonoscopy.

CONCLUSIONS

Colonoscopy plays a major role in the practices of colorectal surgeons across the world, accounting for approximately one-quarter of clinical time and total charges. Based on the expectation that this trend will continue, The American Society of Colon and Rectal Surgeons needs to aggressively support its members not only in the technical aspects of colonoscopy but also in the practice management issues.

Origine et attente des référents antibiotiques dans les établissements de santé en France. Résultats d'une enquête de la SPILF

The French Infectious Diseases Society (SPILF) conducted a web-based survey of physicians' referent for antimicrobial therapy (ABT). The 106 respondents came mostly from public (95%) big (median 815 beds) hospitals. A referent according to health ministry requirements was identified in 88 hospitals. In, 18 others, a physician performed the job without identification per se. This activity had a specific financing in only 12% of cases. Two thirds of the referents were infectious diseases physicians, the others had for training a university degree in ABT. Expectations about SPILF were mostly implementation of good practices of ABT (73%), organization of CME sessions (61%), a referent dedicated session during the annual SPILF meeting (58%), a SPILF driven certification (58%) and the creation of regional networks of referents (55%). Implementing a training and evaluation program for ABT referents becomes a priority for the SPILF.

Can U.S. GI fellowship programs meet American Society for Gastrointestinal Endoscopy recommendations for training in EUS? A survey of U.S. GI fellowship program directors

BACKGROUND

American Society for Gastrointestinal Endoscopy (ASGE) EUS training and credentialing guidelines exist, but the capability of U.S. GI fellowships to meet these guidelines has not been assessed.

OBJECTIVE

To ascertain the capability of U.S. GI fellowship programs to meet ASGE guidelines for EUS training in the context of 3-year and advanced GI fellowships.

METHODS

U.S. GI fellowship programs were surveyed for the presence or the absence, type, and extent of EUS training. Demographics regarding the programs and the program directors were obtained.

MAIN OUTCOME MEASUREMENTS

Data on the annual total EUS volume and data on EUS performed by 3-year and/or advanced-year fellows were collected and analyzed.

RESULTS

Ninety-one of 142 contactable GI programs responded (64%); 72% of programs performed >200 EUS/y and thus could train >or=1 EUS trainee/y. For 3-year GI fellows, 55% received less than 3 months of training, with 43% not receiving actual "hands-on" EUS experience, and 61% not learning EUS-guided FNA. The median EUS performed by 3-year fellows was 50 (0-350). Programs that offer advanced endoscopy fellowship had a median advanced-trainee EUS volume of 200 procedures (range, 50-1100 procedures). Of advanced fellows, 20% failed to receive "hands-on" training and 52% performed <200 procedures. We observed a significant difference in the median EUS volume performed by 3-year versus advanced-year fellows (P<.001). Program director variables did not correlate with training EUS volumes.

CONCLUSIONS

The majority of U.S. GI fellowship programs have established the EUS volume to train at least 1 EUS fellow, per ASGE guidelines; however, most 3-year and many advanced fellows are currently receiving insufficient EUS training.