How to obtain excellent response rates when surveying physicians

Varying ENT practices in adult post-intubation laryngotracheal stenosis after the COVID epidemic in France: A CHERRIES analysis

AIM

The SARS-CoV-2 pandemic may increase the incidence of iatrogenic laryngotracheal stenosis (LTS), whereas management is not well defined. The aim of this study was to survey a panel of French otorhinolaryngologists about their practices and to evaluate their needs.

METHOD

A national-level survey of the management of iatrogenic LTS was conducted using a 41-item questionnaire, in 4 sections, sent to a panel of French otorhinolaryngologists between July and December 2022. The main endpoint was heterogeneity in responses between 55 proposals on LTS management.

RESULTS

The response rate was 20% (52/263). The response heterogeneity rate was 69% (38/55). Heterogeneity concerned general questions on diagnosis (7/12, 58%) and management (7/10, 70%), LTS case management (22/27, 81%), and otorhinolaryngologists' expectations (33%, 2/6). Quality of training was considered good or excellent by only 21% of respondents. More than 80% were strongly in favor of creating national guidelines, expert centers and a national database.

DISCUSSION

This study demonstrated the heterogeneity of adult post-intubation LTS management between otorhinolaryngologists in France. Training quality was deemed poor or mediocre by a majority of respondents. They were in favor of creating national guidelines and expert centers in LTS.

Diagnosing and recording root caries: A survey among Swiss dentists

OBJECTIVES

Despite the increase in the root caries prevalence, little is still known about how dentists manage this condition. The present study aimed to evaluate the knowledge of dentists on diagnosing and recording root caries lesions (RCL).

METHODS

The survey consisted of three domains: (1) dentists' knowledge on diagnosing, recording and managing RCL; (2) information about their current general clinical routines; and (3) their demographics. The four Swiss Universities distributed the survey via e-mail lists for alumni or professionals participating in continuing education. The data was quality checked. Construct validity, internal reliability and intraclass correlation (ICC) were assessed.

RESULTS

The survey was answered by 383 dentists from 25(out of 26) cantons [mean(SD) working experience: 22.5(12) years]. The majority replied that they see less than 5 patients with RCL per week, whereas 41 have at least 5 per week, and 40 % (157 dentists) do not distinguish RCL from coronal caries in their patients' medical records. When diagnosing active RCL, tactile sensation was the most predominant criterion (n = 380), whereas color (n = 224) and visual appearance (n = 129) of the lesion were less often selected. The most often chosen risk factors for RCL were poor oral hygiene and presence of biofilm.The responses were significantly influenced by the participants' place of education, their age and working area.

CONCLUSION

The present survey highlights the huge diversity in diagnosing, recording and assessing risk factors of RCL. The benefits of an appropriate diagnosis, recording and management of risk factors of RCL should be highlighted in under- and postgraduate dental education.

CLINICAL SIGNIFICANCE

A great diversity in diagnosing, recording and assessing risk factors of RCL was observed, which migh strongly impact how dentists manage RCL. The study emphasizes the necessity for intensive efforts to bridge the gap between guideline recommendations and their implementation in private dental practices.

The role of fellowship experience in decreasing burnout for child abuse pediatricians

BACKGROUND

Compassion fatigue and burnout are important issues within the medical field, and may be an even bigger problem for Child Abuse Pediatricians (CAPs). While the Accreditation Council for Graduate Medical Education (ACGME) mandates educational activities focused on burnout and resilience, there is currently minimal data to inform the choice and implementation of these activities.

OBJECTIVE

Our objectives were to: determine the availability and perceived usefulness of educational activities related to burnout and resilience available in CAP fellowships; and explore the relationship between fellowship activities and burnout.

PARTICIPANTS AND SETTING

Surveys were distributed in 2016 to 133 participants in CAP fellowships since 2006.

METHODS

Burnout risk was measured using the Maslach Burnout Inventory - Human Services Survey (MBI-HSS). Logistic regression models were used to assess the association of burnout as measured by the MBI-HSS with specific educational activities.

RESULTS

Of 133 eligible individuals, 85 (64 %) responded. Of these, 40 (53 %) scored in the high-risk range for at least 1 of the three subscales. Activities perceived to be most useful in addressing burnout were: multidisciplinary team interactions, time spent with the team outside of work, and faculty/trainee one-on-one mentorship. Educational activities were only weakly associated with addressing burnout as measured by the MBI-HSS.

CONCLUSIONS

Moderate or high levels of burnout are present in a large proportion of practicing CAPs and more than one-third of participants felt that the quality of burnout training in fellowship did not meet their needs. These data support the need to more effectively address burnout education within the training experience of CAP fellows.

Patient Perceptions of the Impact of the COVID Pandemic on the Quality of Their Gastrointestinal Cancer Care

We surveyed patients who had a received care for a gastrointestinal cancer between 03/2020 and 05/2021 to understand their perceptions of the impact of the Covid pandemic on cancer care delivery and quality of care. Three-hundred fifty-eight respondents provided evaluable responses (response rate: 17.3%). Approximately half of respondents (46.4%) perceived that they had experienced a pandemic-related cancer care modification; most changes were initiated by a clinician or the cancer center (44.6%). Relative to White patients those from Racialized Groups (OR: 1.91, 95% CI: 1.03-3.54) were more likely to report a cancer treatment change. Additionally, relative to patients in follow-up, those who were newly diagnosed (OR: 2.39; 95% CI: 1.21-4.71) were more likely to report a change. Compared to White patients, patients from Racialized Groups were approximately twice as likely to report perceiving that virtual visits during Covid negatively impacted the quality of their care (OR: 2.21; 95% CI: 0.96-5.08). These findings potentially reflect pre-existing systemic disparities in quality of and access to care, as well as differences in how care is experienced by patients from Racialized Groups.

Implementation of medication reconciliation in outpatient cancer care

BACKGROUND

Medication reconciliation (MedRec) is a process where providers work with patients to document and communicate comprehensive medication information by creating a complete medication list (best possible medication history (BPMH)) then reconciling it against what patient is actually taking to identify potential issues such as drug-drug interactions. We undertook an environmental scan of current MedRec practices in outpatient cancer care to inform a quality improvement project at our centre with the aim of 30% of patients having a BPMH or MedRec within 30 days of initiating treatment with systemic therapy.

METHODS

We conducted semi-structured interviews with key stakeholders from 21 cancer centres across Canada, probing on current policies, and barriers and facilitators to MedRec. Guided by the findings of the scan, we then undertook a quality improvement project at our cancer centre, comprising six iterative improvement cycles.

RESULTS

Most institutions interviewed had a process in place for collecting a BPMH (81%) and targeted patients initiating systemic therapy (59%); however, considerable practice variation was noted and completion of full MedRec was uncommon. Lack of resources, high patient volumes, lack of a common medical record spanning institutions and settings which limits access to medication records from external institutions and community pharmacies were identified as significant barriers. Despite navigating challenges related to the COVID-19 pandemic, we achieved 26.6% of eligible patients with a documented BPMH. However, uptake of full MedRec remained low whereby 4.7% of patients had a documented MedRec.

CONCLUSIONS

Realising improvements to completion of MedRec in outpatient cancer care is possible but takes considerable time and iteration as the process is complex. Resource allocation and information sharing remain major barriers which need to be addressed in order to observe meaningful improvements in MedRec.

Ontario family physicians’ perspectives about their scope of practice: what is it, what drives it and how does it change?

Background

There is little evidence to show what scope of practice (SOP) means from the point of view of family physicians, how family physicians think about their SOP as it changes over time, or what factors shape and influence their SOP. Understanding family physician perspectives on SOP and the factors that influence it can aid our understanding of how it can constrain and enable physicians’ agency and autonomy in professional practice.

Methods

Using qualitative description and incorporating constructivist grounded theory data collection and analysis techniques, four focus groups were conducted involving twenty-four Ontario-based family physicians from different contexts, at different career stages, and with different practice experiences.

Results

Participants’ SOP was highly dynamic, changing throughout their careers due to factors both within and beyond their control. Their sense of their own SOP was the product of a continuous cycle of personal and professional transitions, exposures, and experiences throughout their careers. These family physicians sought regular and sustained mentorship, support, and engagement for their SOP throughout their careers. This was particularly the case during professional transitions and for drivers of their SOP for which they felt unprepared early in their careers, such as through the first years of independent practice, and when functioning as owner-operators of medical practices. Four descriptive themes were identified focusing on the nature of their current practice, their professional preparedness and supports, practice management dynamics, and ‘doctors are people, too’.

Conclusions

The SOP of the family physicians in this study was dynamic and unique to each individual, it emerged from interactions between their personal and professional lives and identities, and it was embedded in their lived experiences. SOP was also to some extent imposed and externally driven. This study advances understanding by exploring the ‘why’ and ‘how’ of SOP rather than focusing solely on what it is.

Core implementation strategies for improving cirrhosis care in the Veterans Health Administration

BACKGROUND AND AIMS

The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention.

APPROACH AND RESULTS

VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews.

CONCLUSIONS

In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.

Effectiveness of social giving on the engagement of pharmacy professionals with a computer-based education platform: a pilot randomized controlled trial

BACKGROUND

Computer-based education is gaining popularity in healthcare professional development education due to ease of distribution and flexibility. However, there are concerns regarding user engagement. This pilot study aims to: 1) assess the feasibility and acceptability of a social reward and the corresponding study design; and 2) to provide preliminary data on the impact of social reward on user engagement.

METHODS

A mixed method study combing a four-month pilot randomized controlled trial (RCT), surveys and interviews. The RCT was conducted using a computer-based education platform. Participants in the intervention group had access to a social reward feature, where they earned one meal for donation when completing a quiz with a passing score. Participants in the control group did not have access to this feature. Feasibility and acceptability of the social reward were assessed using surveys and telephone interviews. Feasibility of the RCT was assessed by participant recruitment and retention. User engagement was assessed by number of quizzes and modules completed.

RESULTS

A total of 30 pharmacy professionals were recruited with 15 users in each arm. Participants reported high acceptability of the intervention. The total number of quizzes completed by the intervention group was significantly higher compared to the control group (n = 267 quizzes Vs. n = 97 quizzes; p-value 0.023).

CONCLUSION

The study demonstrates the feasibility and acceptability of a web-based trial with pharmacy professionals and the social reward intervention. It also shows that the social reward can improve user engagement. A future definitive RCT will explore the sustainability of the intervention.

Evaluating the Effectiveness of the Computer-Based Education Platform, Pharmacy5in5, on Pharmacists’ Knowledge of Anticholinergic Toxicity Using a Randomized Controlled Trial

Background: Computer-based education has been widely implemented in healthcare professional development education. However, there has been little examination of the potential for computer-based education to enhance pharmacists’ knowledge. This study aims to assess the effectiveness of computer-based education on improving pharmacists’ knowledge compared to printed education material. Methods: This study was a web-based randomized controlled trial. Participants were randomly allocated to either an intervention group where they had access to the computer-based education module on Pharmacy5in5.ca or to a control group where they had access to printed educational material. Knowledge gain was assessed using a pre- and post-knowledge test. Results: A total of 120 pharmacists were recruited and 101 completed the post-knowledge test (50/60 in the intervention group; 51/60 in the control group). Both groups showed a significant increase in knowledge gain (intervention group: pre-test mean score 19.35 ± 3.56, post-test mean score 22.42 ± 3.812, p value < 0.001; control group pre-test mean score 19.22 ± 3.45, post-test mean score 23.29 ± 3.087, p value < 0.001). However, the difference in knowledge change was not significant between the two groups (22.42 vs. 23.29, p value = 0.333). Conclusions: In this study, a computer-based education module enhanced pharmacists’ knowledge to a similar degree to printed education material. Efforts should be made to provide computer-based education as an option to support pharmacists’ professional development.

How do health professionals translate evidence on early childhood allergy prevention into health literacy-responsive practice? A protocol for a mixed-method study on the views of German health professionals

INTRODUCTION

Paediatricians, general practitioners (GPs) and midwives in primary care are important sources of information for parents on early childhood allergy prevention (ECAP). Research has shown that preventive counselling by health professionals can be effective in improving patients' health literacy (HL) and health behaviour. Providing effective advice relies on two factors. First, health professionals need be up-to-date with research evidence on ECAP, to consider popular misconceptions and fears and to translate this knowledge into clear recommendations for parents (knowledge translation). Second, they need to know and apply counselling techniques and create a practice setting which accommodates parental HL needs (health literacy-responsive care). The objective of this study is to explore and assess how German health professionals take up and translate ECAP evidence into appropriate recommendations for parents, how they consider HL in counselling and practice organisation and what barriers and enablers they find in their performance of HL-responsive ECAP.

METHODS AND ANALYSIS

The study has a sequential mixed-method design, in two phases. In the first phase, qualitative semi-structured expert interviews will be conducted with health professionals (paediatricians, GPs and midwives) at primary care level and professional policy level. Data collection is ongoing until January 2022. In the second phase, based on the qualitative results, a standardised questionnaire will be developed, and pilot-tested in a wider population of German health professionals. The findings of both phases will be integrated.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Ethics Committee of the University of Regensburg (18-1205-101). The results will be published in international peer-reviewed open access journals and via presentations at scientific conferences. The results will also be shared with German health professionals, decision-makers and potential funders of interventions.

Effect of prenotification on the response rate of a postal survey of emergency physicians: a randomised, controlled, assessor-blind trial

OBJECTIVES

Response rates to physician surveys are typically low. The objective of this study was to determine the effect of a prenotification letter on the response rate of a postal survey of emergency physicians.

DESIGN

This was a substudy of a national, cross-sectional postal survey sent to emergency physicians in Canada. We randomised participants to either receive a postal prenotification letter prior to the survey, or to no prenotification letter.

PARTICIPANTS

A random sample of 500 emergency physicians in Canada. Participants were selected from the Canadian Medical Directory, a national medical directory which lists more than 99% of practising physicians in Canada.

INTERVENTIONS

Using computer-generated randomisation, physicians were randomised in a concealed fashion to receive a prenotification letter approximately 1 week prior to the survey, or to not receive a prenotification letter. All physicians received an unconditional incentive of a $3 coffee card with the survey instrument. In both groups, non-respondents were sent reminder surveys approximately every 14 days and a special contact using Xpresspost during the final contact attempt.

OUTCOME

The primary outcome was the survey response rate.

RESULTS

201 of 447 eligible physicians returned the survey (45.0%). Of 231 eligible physicians contacted in the prenotification group, 80 (34.6%) returned the survey and among 237 eligible physicians contacted in the no-prenotification group, 121 (51.1%) returned the survey (absolute difference in proportions 16.5%, 95% CI 2.5 to 30.5, p=0.01).

CONCLUSION

Inclusion of a prenotification letter resulted in a lower response rate in this postal survey of emergency physicians. Given the added costs, time and effort required to send a prenotification letter, this study suggests that it may be more effective to omit the prenotification letter in physician postal surveys.

Practice variation in the informed consent procedure for thrombolysis in acute ischemic stroke: a survey among neurologists and neurology residents

Background

Obtaining informed consent for intravenous thrombolysis in acute ischemic stroke can be challenging, and little is known about if and how the informed consent procedure is performed by neurologists in clinical practice. This study examines the procedure of informed consent for intravenous thrombolysis in acute ischemic stroke in high-volume stroke centers in the Netherlands.

Methods

In four high volume stroke centers, neurology residents and attending neurologists received an online questionnaire concerning informed consent for thrombolysis with tissue-type plasminogen activator (tPA). The respondents were asked to report their usual informed consent practice for tPA treatment and their considerations on whether informed consent should be obtained.

Results

From the 203 invited clinicians, 50% (n = 101) completed the questionnaire. One-third of the neurology residents (n = 21) and 21% of the neurologists (n = 8) reported that they always obtain informed consent for tPA treatment. If a patient is not capable of providing informed consent, 30% of the residents (n = 19) reported that they start tPA treatment without informed consent. In these circumstances, 53% of the neurologists (n = 20) reported that the resident under their supervision would start tPA treatment without informed consent. Most neurologists (n = 21; 55%) and neurology residents (n = 45; 72%) obtained informed consent within one minute. None of the respondents used more than five minutes for informed consent. Important themes regarding obtaining informed consent for treatment were patients’ capacity, and medical, ethical and legal considerations.

Conclusion

The current practice of informed consent for thrombolysis in acute ischemic stroke varies among neurologists and neurology residents. If informed consent is obtained, most clinicians stated to obtain informed consent within one minute. In the future, a shortened information provision process may be applied, making a shift from informed consent to informed refusal, while still considering the patient’s capacity, stroke severity, and possible treatment delays.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00684-6.

Identifying barriers, facilitators and behaviour change techniques to the adoption of the full scope of pharmacy practice among pharmacy professionals: Using the Theoretical Domains Framework

BACKGROUND

As pharmacy evolves, pharmacy professionals continue to struggle to practice to their full scope. A theoretically-informed intervention to change practice can support pharmacy professionals in providing full scope services. The Theoretical Domains Framework (TDF) can inform the design of a behaviour change intervention to improve the uptake of full scope services among pharmacy professionals.

OBJECTIVES

This study aimed to: (1) identify barriers and facilitators influencing the adoption of full scope services among pharmacy professionals, and (2) identify optimal behaviour change techniques (BCTs) to address the identified barriers and facilitators.

METHODS

A three-step, mixed method study was conducted. First, a 24-item TDF-based survey was sent via email to users of a national computer-based educational platform (n = 2696). Second, TDF-based interviews were conducted with a convenient sample of survey respondents and analyzed using the framework method. Finally, validated linkages were used to link BCTs with corresponding barriers and facilitators, then interview data were analyzed using a deductive approach to guide the selection of the BCTs.

RESULTS

A total of 225 participants completed the survey and 24 telephone interviews were conducted (17 pharmacists, 7 pharmacy technicians). A number of key barriers were identified on an individual level (e.g., lack of clear professional identity and limited decision-making skills in ambiguous cases) and on an organizational level (e.g., lack of social support from managers and concerns about making more errors with the current workflow). Mapping the barriers and facilitators to BCTs yielded 18 BCTs to support the adoption of full scope services, including modeling, rehearsal/practice, and social support.

CONCLUSIONS

This study highlighted several barriers that need to be addressed to facilitate pharmacy professionals working to their full scope, including professional collaboration, professional identity, and adequate training. A comprehensive intervention combining skills training with modeling, social support, and decision-making tools could encourage practice change.

Understanding the Need for Tools and Resources to Manage Enteral Nutrition Intolerance: An On-line Survey

Purpose: Enteral nutrition intolerance (ENI) is a common complication among tube-fed patients, associated with reduced volumes of nutrition delivered, and may contribute to malnutrition risk. This research aimed to obtain insights about dietitians' needs and preferences related to tools and resources to help identify and manage ENI.Methods: An online survey was administered to registered dietitians (RD) engaged in enteral nutrition (EN) management, recruited from a list of attendees at a national webinar. The 16-question survey asked about participant's experience with ENI and interest in resources to manage ENI.Results: Of the 219 surveys completed (25% response rate), 86% identified ENI as an issue/concern that interferes with adequate nutrition or hydration for their patients. Ninety-seven percent reported being interested in having tools/resources to manage ENI. The symptoms identified as most pressing to manage were diarrhea (73%), bloating/abdominal discomfort (42%), and nausea (32%). Preferred types of tools were hard-copy resources (70%), algorithms (67%), and web-based instruments (62%).Conclusions: ENI remains an issue for clinicians working with tube-fed patients and RDs are interested in management tools. These results have implications for the development of evidence-based resources to help improve EN delivery and ultimately may contribute to clinician's efforts at reducing malnutrition.

Examining the extent and factors associated with interprofessional teamwork in primary care settings

Despite growing emphasis on adopting team-based models of primary care to facilitate patient access to a diverse range of care providers, our understanding of team functioning within primary care teams remains limited. This study examined interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers - [CHC]) in Ontario and explored team-level and organizational factors associated with interprofessional teamwork. Interprofessional teamwork was measured using the Collaborative Practice Assessment Tool (CPAT), which was completed by providers in each participating team. The CPAT responses of 988 providers representing on average 12 professions (sd = 2.1) across 66 teams (44 FHTs and 22 CHCs) were included in the analysis. The average CPAT score was 46.6 (sd = 2.5). CHCs had significantly higher CPAT scores than FHTs (m_diff = 1.7, p = .02). Using diverse communication mechanisms to share information, increasing quality improvement capacities, and age of practice, had a statistically significant positive association with CPAT scores. Increasing team size, using centralized administrative processes, a high level of information exchange, and having a mixed governance board were significantly negatively associated with CPAT score. Findings illustrate factors associated with interprofessional teamwork and offer insight into the comparative performance of two team-based primary care models in Ontario.

Recruiting general practitioners and patients with dementia into a cluster randomised controlled trial: strategies, barriers and facilitators

Background

Recruitment of general practitioners (GPs) and their patients is reported as one of the most challenging steps when undertaking primary care research. The present paper describes the recruitment process of a cluster randomised controlled trial (cRCT) aiming to improve dementia care in the primary care setting.

Methods

Recruitment data was analysed descriptively using frequency tables to investigate comparisons of recruitment rates and results of different recruitment strategies as well as reasons for participation and non-participation of GPs, patients with dementia (PwD) and their caregivers.

Results

Over a period of 23 months, N = 28 GPs were successfully included in the cRCT. This represents an overall recruitment rate of 4.6%. The most efficient strategy in terms of high response and low labour-intensity involved the dissemination of calls for participation in a GP research network. Most frequently reported reasons for GP’s participation were Improvement of patient’s well-being (n = 22, 79%) followed by Interest in dementia research (n = 18, 64%). The most common reasons for non-participation were Lack of time (n = 71, 34%) followed by Not interested in participation (n = 63, 30%). On a patient level, N = 102 PwD were successfully recruited. On average, each GP referred about n = 7 PwD (range: 1–17; mdn = 6; IQR = 3.5) and successfully recruited about n = 4 PwD (range: 1–11; mdn = 3; IQR = 3.5).

Conclusion

First, our findings propose GP research networks as a promising strategy to promote recruitment and participation of GPs and their patients in research. Second, present findings highlight the importance of including GPs and their interests in specific research topics in early stages of research in order to ensure a successful recruitment. Finally, results do not support cold calls as a successful strategy in the recruitment of GPs.

Trial registration

The trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN15854413). Registered 01 April 2019.

Life chances after surgery of congenital heart disease: A case-control-study of inter- and intragenerational social mobility over 15 years

Background

Patients of congenital heart disease surgery have good prospects for reaching old age. Against the backdrop of increasing life expectancies, the question of how well such patients are mastering daily routines and their working life emerges. In our study, the educational and occupational performance of patients over 15 years was examined.

Methods

Intergenerational social mobility (changes in social positions from the parental generation to the generation of children) was examined in terms of education, and intragenerational social mobility (changes in positions within the same generation, i.e., in individuals over their life courses) was examined in terms of occupational positions. Comparisons were made between patients and a control group drawn from the German Socio-Economic Panel (SOEP). Controls were drawn from respondents who participated in the 2004 and 2018 SOEP surveys.

Results

The data were from 244 out of 360 patients (68%) with complete social data from the first survey (2003–2004) and who were included in the follow-up (2017–2019), and 238 controls were drawn from the SOEP. At the time of the second survey, subjects’ ages ranged from 28 to 59 years of age (M = 40.1 years). Intergenerational educational mobility did not differ between cases and controls. For intragenerational social mobility, downward changes were more frequent among controls. This latter finding may be explained by patients retiring earlier than the general population. Retirement rates increased over time, particularly among patients with severe congenital malformations. Unemployment rates were also higher among patients.

Conclusions

Taken together, although a considerable proportion of patients with congenital heart disease retired prematurely or never entered the labour force, their educational and occupational careers proceeded more favourably than expected.

The effect of a web-push survey on physician survey responses rates: a randomized experiment

Background

Achieving a high response rate for physicians has been challenging, and with response rates declining in recent years, innovative methods are needed to increase rates. An emerging concept in survey methodology has been web-push survey delivery. With this delivery method, contact is made by mail to request a response by web. This study explored the feasibility of a web-push survey on a national sample of physicians.

Methods

A total of 1,000 physicians across six specialties were randomly assigned to a mail-only or web-push survey delivery. Each mode consisted of four contacts including an initial mailing, reminder postcard, and two additional follow-ups. Response rates were calculated using the American Association for Public Opinion Research's response rate 3 calculation. Data collection occurred between Febuary and April 2018; data were analyzed March 2019.

Results

Overall reponse rates for the mail-only versus web-push survey delivery were comparable (51.2% vs. 52.8%). Higher response rates across all demographics were seen in the web-push delivery, with the exception of pulmonary/critical care and physicians over the age of 65. The web-push survey yielded a greater response after the first mailing, requiring fewer follow-up contacts resulting in a more cost-effective delivery.

Conclusions

A web-push mail survey is effective in achieving a comparable response rate to traditional mail-only delivery for physicians. The web-push survey was more efficient in terms of cost and in receiving responses in a more timely manner. Future research should explore the efficiency of a web-push survey delivery across various health care provider populations.

Family medicine physicians' report strong support, barriers and preferences for Registered Dietitian Nutritionist care in the primary care setting

BACKGROUND

Previous studies have examined barriers (e.g. time) for Family Medicine Providers (FMPs) to provide nutrition and lifestyle counseling, however, to date no studies have examined access or interest to Registered Dietitian Nutritionist (RDN) care for patients.

OBJECTIVE

The objective of this study was to explore FMP access, referral practices, barriers and preferences for RDN care.

METHODS

A cross-sectional online survey, with content and face validation was conducted with Family Medicine Departments within large academic health care systems in the Southeastern United States. The main variables of interest included: FMP access, interest, current referrals and referral preferences for RDN care, barriers to referrals and overall perceptions regarding RDN care. Descriptive analysis of close-ended responses was performed with SPSS 26.0. Open-ended responses were analysed using inductive content analysis.

RESULTS

Over half of the respondents (n = 151) did not have an RDN on-site (64%) yet were highly interested in integrating an RDN (94.9%), with reported preferences for full-time on-site, part-time on-site or off-site RDN care (49.1%, 39.5% and 11.4% respectively). The greatest reported barriers to RDN referrals were perceived cost for the patient (64.47%) and uncertainty how to find a local RDN (48.6%). The most consistent theme reported in the open-ended responses were concerns regarding reimbursement, e.g. 'Insurance does not cover all of the ways I would like to use an RDN'.

CONCLUSIONS

FMPs report interest and value in RDN services despite multiple perceived barriers accessing RDNs care. Opportunities exist for interprofessional collaboration between dietetic and FMP professional groups to address barriers.

Evaluation of the effectiveness of the Global Medical Student Partnership program in undergraduate medical education

BACKGROUND

The Global Medical Student Partnership (GMSP) is a medical student-led international initiative to promote accessible global health learning. This study aims to evaluate the effectiveness of the GMSP program in meeting its learning objectives.

METHODS

Canadian and international medical student pairs met online monthly (January-May 2018) to discuss global health-related medical cases. Students then reviewed cases with local GMSP peers and faculty experts. A mixed-methods study was performed to evaluate whether the objectives of the program had been achieved. 26 of 32 (81.3%) students completed a questionnaire, and 13 (40.6%) also participated in one-on-one semi-structured interviews. Descriptive statistics and thematic analysis were used to analyze students' perspectives on skill development through GMSP.

RESULTS

GMSP students agreed or strongly agreed that international collaboration and communication skills were more important to them following program participation (92.3%, 92.3% respectively). Many expressed that after GMSP, they knew more about their healthcare system, practices abroad and how to solve complex health issues (92.3%, 84.6%, 61.5% respectively). Qualitative data showed GMSP improved students' communication and presentation skills, provided a foundation for international relationships, fostered appraisal of diverse health systems, and furthered students' understanding of health advocacy.

CONCLUSIONS

Our findings demonstrate that GMSP met its original objectives by providing students with opportunities to engage in international collaborations and to further develop their skills in advocacy, communication, and health-systems research. This program may be an important addition to medical education as it makes use of technology and peer-to-peer exchange to enable global health learning.

Selection bias in general practice research: analysis in a cohort of pregnant Danish women

OBJECTIVE

The aim of the present study was to examine selection in a general practice-based pregnancy cohort.

DESIGN

Survey linked to administrative register data.

SETTING AND SUBJECTS

In spring 2015, GPs were recruited from two Danish regions. They were asked to invite all pregnant women in their practice who had their first prenatal care visit before 15 August 2016 to participate in the survey.

OUTCOME MEASURES

The characteristics of GPs and the pregnant women were compared at each step in the recruitment process - the GP's invitation, their agreement to participate, actual GP participation, and the women's participation - with an uncertainty coefficient to quantify the step where the largest selection occurs.

RESULTS

Significant differences were found between participating and non-participating practices with regards to practice characteristics such as the number of patients registered with the practice, the age and sex of doctors, and the type of practice. Despite these differences, the characteristics of the eligible patients differed little between participating and non-participating practices. In participating practices significant differences were, however, observed between recruited and non-recruited patients.

CONCLUSION

The skewed selection of patients was mainly caused by a high number of non-participants within practices that actively took part in the study. We recommend that a focus on the sampling within participating practices be the most important factor in representative sampling of patient populations in general practice. Key points Selection among general practitioners (GPs) is often unavoidable in practice-based studies, and we found significant differences between participating and non-participating practices. These include practice characteristics such as the number of GPs, the number of patients registered with the GP practice, as well as the sex and age of the GPs. •Despite this, only small differences in the characteristics of the eligible patients were observed between participating and non-participating practices. •In participating practices, however, significant differences were observed between recruited and non-recruited patients. •Comprehensive sampling within participating practices may be the best way to generate representative samples of patients.

Getting to implementation: a protocol for a Hybrid III stepped wedge cluster randomized evaluation of using data-driven implementation strategies to improve cirrhosis care for Veterans

BACKGROUND

Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care.

METHODS

Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these "data-driven" implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs' use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care.

DISCUSSION

Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices.

TRIAL REGISTRATION

This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.

Checking the pulse in the 21st century: Interobserver reliability of carotid pulse detection by point-of-care ultrasound

INTRODUCTION

Detection of a pulse is crucial to decision-making in the care of patients who are in cardiac arrest, however, the current standard of manual pulse palpation is unreliable. An emerging alternative is the use of point-of-care ultrasound (POCUS) for direct assessment of the carotid pulse. The primary objective of this study is to determine the interobserver reliability for physician interpretation of pre-recorded point-of-care ultrasound pulse-check clips for patients who are in cardiac arrest.

METHODS

We conducted a web-based survey of residents and physicians working in an academic center. Participants were shown a tutorial demonstrating POCUS detection of the carotid pulse and then asked to interpret 15 carotid pulse ultrasound clips from patients who were in cardiac arrest. The primary outcome was interobserver reliability for carotid pulse assessment. Secondary outcomes included interobserver reliability stratified by physician role and POCUS experience, median tutorial and median pulse assessment duration. Interobserver reliability was determined by Krippendorff's ⍺.

RESULTS

68 participants completed the study, with a response rate of 75%. There was high interobserver reliability for pulse assessment amongst all study participants (⍺ = 0.874, 95% CI 0.869 to 0.879). All sub-groups had ⍺ greater than 0.8. Median tutorial duration was 35 s (IQR 29). Median pulse assessment duration was 6 s (IQR 5) with 76% of assessments completed within 10 s.

CONCLUSION

Interpretation of the carotid pulse by POCUS showed high interobserver reliability. Further work must be done to determine the performance of POCUS pulse assessment in real-time for patients who are in cardiac arrest.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach

BACKGROUND

Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients.

METHODS

We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project.

RESULTS

Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations.

DISCUSSION

Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease.

CONCLUSIONS

Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Medical ethics: knowledge, attitude and practice among doctors in three teaching hospitals in Sri Lanka

BACKGROUND

Medical ethics deals with the ethical obligations of doctors to their patients, colleagues and society. The annual reports of Sri Lanka Medical Council indicate that the number of complaints against doctors has increased over the years. We aimed to assess the level of knowledge, attitude and practice regarding medical ethics among doctors in three teaching hospitals in Sri Lanka.

METHODS

A hospital-based cross-sectional study was conducted among doctors (n = 313) using a pre-tested self-administered, anonymous questionnaire. Chi Squared test, and ANOVA test were used to identify the significance of association between level of knowledge and selected factors.

RESULTS

Most doctors (81.2%) had a poor level of knowledge on medical ethics, with postgraduate trainees showing significantly (p = 0.023, Chi square) higher level of knowledge. The average knowledge on medical ethics among doctors was significantly different between the three hospitals (p = 0.008, ANOVA). Over 95% had a favourable attitude towards gaining knowledge and advocated the need for training. The majority (69.3%) indicated awareness of unethical practices. 24.6% of respondents stated that they get a chaperone 'sometimes' during patient examination while 3.5% never do. The majority (54%) responded that they never accept gifts from pharmaceutical companies in recognition of their prescribing pattern. 12-41% of doctors participated in the study acknowledged that they 'sometime' engaged in unethical practices related to prescribing drugs, accepting gifts from pharmaceutical companies and when obtaining leave.

CONCLUSION

Most doctors had a poor level of knowledge of medical ethics. Postgraduate trainees had a higher level of knowledge than other doctors. The majority showed a favourable attitude towards gaining knowledge and the need of training. Regular in-service training on medical ethics for doctors would help to improve their knowledge on medical ethics, as well as attitudes and ethical conduct.

Pediatric Orthopaedists Are Not Immune: Characterizing Self-reported Burnout Rates Among POSNA Members

BACKGROUND

There are no published data characterizing burnout rates for pediatric orthopaedic surgeons. The primary purpose of this study was to identify the rates of self-reported personal and team burnout among members of the Pediatric Orthopaedic Society of North America (POSNA). A secondary aim was to determine whether specific demographic variables were more likely to be associated with self-reported burnout.

METHODS

During its 2018 annual meeting, the POSNA Wellness Taskforce launched a web-based survey in which members were asked to respond to 2 previously validated questions related to personal and team burnout. The survey was distributed by a closed POSNA membership e-mail list and responses were analyzed anonymously. Descriptive statistics were calculated. Pearson χ testing was used to analyze differences in burnout rates as a function of age and sex.

RESULTS

A total of 615 POSNA members completed the survey, a 47% response rate. Overall, 38% reported personal burnout and 46% reported team burnout. Women were more likely to report both personal (P<0.001) and team burnouts (P<0.005). Members aged 40 to 59 years were more likely to report personal burnout, irrespective of sex (P<0.001). Members aged 50 to 59 years were more likely than those in other age groups to report team burnout (P<0.001). There was no significant association found between the presence of burnout and either race, ethnicity, LGBTQ status, or educational background.

CONCLUSIONS

As a group, pediatric orthopaedists report moderately high rates of both personal and team member burnout. Individual-specific factors such as age and sex may play an important role in determining one's risk for experiencing burnout. Recognizing that burnout affects a significant minority of POSNA members is a crucial first step.

LEVEL OF EVIDENCE

Level III.

Survey of the Knowledge, Attitudes and Practices of Primary Care Physician's Towards Dementia Care in Israel

Aim: Primary care physicians have an important role in the early diagnosis and management of dementia as a common first point of contact for patients dealing with cognitive decline. Our aim was to explore primary care physicians knowledge, attitudes, and practices regarding care of people with dementia and their families. Methods: A cross sectional study among primary care physicians, attending their annual conference. The self-complete questionnaire included questions measured with a five point Likert scale as well as open-ended questions. Multivariable linear regression models were used to evaluate primary care physicians confidence in their dementia diagnosis and their level of knowledge and training. Results: Questionnaires were returned by 95 primary care physicians, a 24% response rate. The majority of primary care physicians feel it is their role to diagnose dementia (87%), unfortunately, 80% do not feel confident in making this diagnosis and 66% feel they are lacking knowledge or training to do so. They report they need more training on non-pharmacological interventions (86%), pharmacological treatments (92%), and community services (92%). Regression analysis revealed that lack of easily accessible screening tools plays an important role in confidence in dementia diagnosis. Conclusion: Our results may help policy makers plan interventions to meet training and system needs of primary care physicians and translate the national dementia policy guidelines into practice at the local level. Keywords: physicians, primary care, dementia, early diagnosis, adult day care centers

Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters

PURPOSE

Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography.

METHODS

We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS.

RESULTS

Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion "most of the time" or "always," none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion.

CONCLUSIONS

Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.

Compliance of Primary Care Providers With Gout Treatment Recommendations—Lessons to Learn: Results of a Nationwide Survey

Objectives: Gout is generally managed in the primary health care sector. Compliance of primary care physicians with gout management recommendations has been shown to be insufficient in the past. The primary aims of this study were to assess primary care providers' knowledge regarding gout and to determine if their treatment decisions are influenced by recommendations. Facing considerable variations in postgraduate training options in Austria, we secondly looked for possible knowledge differences between urban and rural areas and eastern and western parts of Austria.

Methods: We conducted a survey among 343 primary care physicians in Austria, using a questionnaire consisting of 10 questions on acute, intercritical and general gout management. Gout treatment recommendations served as the therapeutic gold standard.

Results: Of the 343 physicians surveyed, 336 completed the questionnaire, leading to a very high return rate of 98%. 289 (86%) physicians were aware of the agreed-upon SUA target (<6 mg/dl). 323 (96.1%) reported change of therapy in case of missing this target. 112 (33.3%) physicians voted for long term ULT. No geographical differences in knowledge regarding gout or its management were revealed, except that colchicine was rated as being a safe medication significantly more often in rural areas (p = 0.035) and in western Austria (p = 0.014).

Conclusion: As opposed to former studies, gout knowledge among primary care physicians has improved - however, treatment patterns are still not fully concordant with gout recommendations. Our findings may help to better tailor future postgraduate training to improve primary care physicians' education in gout.

Mixed-methods approach to understanding clinician macrocognition in the design of a clinical decision support tool: a study protocol

INTRODUCTION

The anatomic variants of congenital heart disease (CHD) are multiple. The increased survival of these patients and disposition into communities has led to an increase in their acute presentation to non-CHD experts in primary care clinics and emergency departments. Given the vulnerability and fragility of these patients in the face of acute illness, new clinical decision support systems (CDSS) are urgently needed to better translate the best practice recommendations for the care of these patients. This study aims to understand the perceived confidence and macrocognitive processes of non-CHD experts (emergency medicine physicians) and CHD experts (paediatric cardiac intensivists) when treating children with CHD during acute illness and apply this to optimise the design of a CDSS (MyHeartPass^™) for these patients.

METHODS AND ANALYSIS

The first phase of the study involves a survey of non-CHD experts and CHD experts to understand their perceived confidence as it relates to treating acutely ill patients with CHD. The second phase is a qualitative cognitive task analysis using critical decision method to characterise and compare the macrocognitive processes used by non-CHD experts and CHD experts during the critical decision making. In phases 3 and 4, heuristic evaluation and usability testing of the CDSS will be completed. These results will be used to inform design changes to the chosen CDSS (MyHeartPass^™). In the final phase, a within-participant simulation design will be used to study the effect of the CDSS on clinical decision making compared with baseline (without use of CDSS).

ETHICS AND DISSEMINATION

Ethics approval from The Hospital for Sick Children in Toronto, Ontario, Canada has been obtained for all phases. Results will be published in peer-reviewed journals and presented at relevant conferences. On successful completion of these studies, it is anticipated that there will be a controlled implementation of the redesigned CDSS.

Facilitators and barriers in anorexia nervosa treatment initiation (FABIANA): study protocol for a mixed-methods and multicentre study

BACKGROUND

Anorexia nervosa is a serious disorder, which often takes a chronic course. Early treatment leads to a significantly better prognosis and prevents chronicity. However, existing evidence on facilitators and barriers in anorexia nervosa treatment initiation is scarce.

AIMS

Against this background, the FABIANA study (ClinicalTrials.gov Identifier: NCT03713541) aims to (a) identify potentially modifiable facilitators and barriers from the perspectives of adolescent and adult patients with anorexia nervosa, carers and physicians, (b) develop and test an instrument for the combined assessment of multiple key facilitators and barriers, and (c) quantify the effect of potentially modifiable versus non-modifiable key facilitators and barriers on the duration of untreated illness (DUI) in patients with anorexia nervosa.

METHOD

FABIANA is an observational, mixed-method-study divided into three consecutive substudies each corresponding to one of the study aims. All three substudies will include female patients with anorexia nervosa aged 14 years and older at the beginning of their first psychotherapeutic anorexia nervosa treatment. The qualitative substudy I and the quantitative substudy III will additionally include carers and involved physicians. The recruitment will take place at 20 cooperating study centres throughout Germany, which provide in-patient or out-patient anorexia nervosa specialist care. The DUI will be calculated based on the month of illness onset as determined in validated interviews on lifetime anorexia nervosa symptoms and the therapist-reported date of treatment initiation.

CONCLUSIONS

Strengths and limitations of the retrospective assessment of the DUI will be discussed. The findings of the FABIANA study will contribute to the development of evidence-based early-intervention approaches and the prevention of a chronic course of illness.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03713541.

DECLARATION OF INTEREST

None.

Motivations and willingness of general practitioners in France to participate in primary care research as investigators

BACKGROUND

Clinical research is mostly conducted among hospitalized patients, which restricts the generalizability of research results. The involvement of GPs in research has been consistently highlighted as a factor associated with successful study recruitment.

OBJECTIVES

To assess GPs' motivations and willingness to participate in primary care research as investigators and to identify factors associated with their willingness.

METHODS

We conducted an observational, cross-sectional study in Normandy, France, with a self-questionnaire sent to 3002 GPs. We collected data on GPs' socio-demographic characteristics, their experiences and their expectations regarding research, and their reasons for non-participation.

RESULTS

Overall, 489 questionnaires were collected. Two hundred and forty-six GPs (50.3%) were interested in participating in clinical research as investigators. The two main conditions for participation as investigators were the relevance of the study topic for clinical practice (80.5%) and the feedback of study results (80.1%). The two main reasons for non-participation were lack of time (79.4%) and administrative burden (43.6%). Age between 27 and 34 years (adjusted odds ratio [AOR] = 2.86, P = 0.004) and GP trainer status (AOR = 2.41, P < 0.001) were associated with willingness to participate in primary care research. Age between 60 and 70 years (AOR = 0.53, P = 0.03) and locum status (AOR = 0.40, P = 0.04) were associated with non-participation in research.

CONCLUSIONS

Based on our results, we were able to establish a profile of GPs willing to participate in primary care research as investigators. GPs' involvement should be based on their preferred areas of research. Different incentives such as a dedicated clinical research nurse or financial support could also be considered.

Advancing regulatory science and assessment of FDA REMS programs: A mixed-methods evaluation examining physician survey response

Purpose:

Food and Drug Administration’s (FDA) Draft Guidance for Industry on pharmaceutical REMS (Risk Evaluation and Mitigation Strategies) assessment and survey methodology highlights physician knowledge–attitudes–behaviors (KAB) surveys as regulatory science tools. This mixed-methods evaluation advances regulatory science and the assessment of FDA REMS programs when using physician surveys. We: (1) reviewed published physician survey response rates; and (2) assessed response bias in a simulation study of secondary survey data using different accrual cut-off strategies.

Methods:

A systematic literature review was conducted of US physician surveys (2000–2014) on pharmaceutical use (n = 75). Kruskal–Wallis tests were used to examine the relationships between response rates and survey design characteristics. The simulation was conducted using secondary data from a population-based physician KAB survey on diabetes risk management with antipsychotic use in Missouri Medicaid (n = 973 accrued over 30 weeks). Survey item responses were compared using Pearson’s chi-square tests for two faster completion simulations: Fixed Sample (n = 300) and Fixed Time (8 weeks).

Results:

Survey response rates ranged from 7% to 100% (median = 48%, IQR = 34%–68%). Surveys of targeted populations and surveys using member lists were associated with higher response rates (p = 0.02). In the simulation, 9 of 20 (45%) KAB items, including diabetes screening advocacy, differed significantly using the smaller Fixed Sample strategy (achieved in 12 days) versus full accrual. Fewer response differences were found using the Fixed Time strategy (2 of 20 [10%] items).

Conclusions:

Published data on physician surveys report low response rates with most associated with the sample source selected. FDA REMS assessments should include formal evaluation of survey accrual and response bias.

Opinions and Practices of Lung Cancer Screening by Physician Specialty

BACKGROUND In response to the National Lung Screening Trial, numerous professional organizations published guidelines recommending annual lung cancer screening with low-dose computed tomography (LDCT) for high-risk patients. Prior studies found that physician attitudes and knowledge about lung cancer screening directly impacts the number of screening exams ordered.METHODS In 2015, we surveyed 34 pulmonologists and 186 primary care providers (PCPs) to evaluate opinions and practices of lung cancer screening in a large academic medical center. We compared PCP and pulmonologist responses using t-tests and χ² tests.RESULTS The overall survey response rate was 40% (39% for PCPs and 50% for pulmonologists). Pulmonologists were more likely than PCPs to report lung cancer screening as beneficial for patients (88.2% versus 37.7%, P < .0001) and as being cost-effective (47.1% versus 14.3%, P = .02). More pulmonologists (76%) reported ordering a LDCT for screening in the past 12 months compared to PCPs (41%, P = .012). Pulmonologists and PCPs reported similar barriers to referring patients for lung cancer screening, including patient costs (82.4% versus 77.8%), potential for emotional harm (58.8% versus 58.3%), high false positive rate (47.1% versus 69.4%), and likelihood for medical complications (47.1% versus 59.7%).LIMITATIONS Our results are generalizable to academic medical centers and responses may be susceptible to recall bias, non-response bias, and social desirability bias.CONCLUSION We found significant differences in opinions and practices between PCPs and pulmonologists regarding lung cancer screening referrals and perceived benefits. As lung cancer screening continues to emerge in clinical practice, it is important to understand these differences across provider specialty to ensure screening is implemented and offered to patients appropriately.

Perspectives on Monitoring Youth with Ongoing Mental Health Problems in Primary Health Care: Family Physicians Are "Out of the Loop"

Children's mental health (CMH) problems often recur. Following specialized mental health treatment, youth may require monitoring and follow-up. For these youth, primary health care is highly relevant, as family physicians (FPs) are the only professionals who follow patients across the lifespan. The current study gained multiple perspectives about (1) the role of FPs in caring for youth with ongoing/recurring CMH problems and (2) incorporating routine mental health monitoring into primary health care. A total of 33 interviews were conducted, including 10 youth (aged 12-15) receiving CMH care, 10 parents, 10 CMH providers, and 3 FPs. Using grounded theory methodology, a theme of FPs being "out of the loop" or not involved in their patient's CMH care emerged. Families perceived a focus on the medical model by their FPs and believed FPs lacked mental health expertise. Findings indicate a need for improved collaboration between CMH providers and FPs in caring for youth with ongoing CMH problems.

Operating Room Supply Cost Awareness: A Cross-Sectional Analysis

Introduction

We assessed surgeon knowledge of commonly used instruments and disposable items and described attitudes toward incorporating cost data into daily practice.

Methods

An electronic, e-mail based survey was distributed to faculty and trainees in the University of California San Francisco (UCSF) Department of Urology. The 26-question survey assessed opinions regarding general operating room supply cost information and specific costs of 10 supplies used for laparoscopic nephrectomy. A response was considered accurate when it fell within 50% of the actual cost.

Results

The response rate was 71% among faculty (13) and 90% among trainees (17). Overall 55% of faculty and 82% of trainees considered their knowledge of costs "fair" or "poor." The overall accuracy of cost estimation for 10 commonly used supply items was 27% (SD ± 45%), with no significant difference between trainees and faculty (p=0.70). Accuracy was not associated with self-reported cost knowledge (p=0.25) or number of laparoscopic nephrectomies performed (p=0.47). Of the faculty 33% and of the trainees 41% reported that having more knowledge of costs would motivate them to decrease their operating room supply costs, and 42% of faculty raised the idea of an incentive program. Overall 75% of study participants believe that there is "too little" or "not enough" emphasis placed on cost awareness.

Conclusions

Trainees and faculty generally have poor knowledge of operating room supply costs. In our academic setting we noted an interest among faculty and residents to make cost data more accessible. These data would provide an opportunity for surgeons to act as cost arbiters in the operating room.

Longitudinal assessment of the association between implementation strategy use and the uptake of hepatitis C treatment: Year 2

BACKGROUND

To increase the uptake of evidence-based treatments for hepatitis C (HCV), the Department of Veterans Affairs (VA) established the Hepatitis Innovation Team (HIT) Collaborative. Teams of providers were tasked with choosing implementation strategies to improve HCV care. The aim of the current evaluation was to assess how site-level implementation strategies were associated with HCV treatment initiation and how the use of implementation strategies and their association with HCV treatment changed over time.

METHODS

A key HCV provider at each VA site (N = 130) was asked in two consecutive fiscal years (FYs) to complete an online survey examining the use of 73 implementation strategies organized into nine clusters as described by the Expert Recommendations for Implementing Change (ERIC) study. The number of Veterans initiating treatment for HCV, or "treatment starts," at each site was captured using national data. Providers reported whether the use of each implementation strategy was due to the HIT Collaborative.

RESULTS

Of 130 sites, 80 (62%) responded in Year 1 (FY15) and 105 (81%) responded in Year 2 (FY16). Respondents endorsed a median of 27 (IQR19-38) strategies in Year 2. The strategies significantly more likely to be chosen in Year 2 included tailoring strategies to deliver HCV care, promoting adaptability, sharing knowledge between sites, and using mass media. The total number of treatment starts was significantly positively correlated with total number of strategies endorsed in both years. In Years 1 and 2, respectively, 28 and 26 strategies were significantly associated with treatment starts; 12 strategies overlapped both years, 16 were unique to Year 1, and 14 were unique to Year 2. Strategies significantly associated with treatment starts shifted between Years 1 and 2. Pre-implementation strategies in the "training/educating," "interactive assistance," and "building stakeholder interrelationships" clusters were more likely to be significantly associated with treatment starts in Year 1, while strategies in the "evaluative and iterative" and "adapting and tailoring" clusters were more likely to be associated with treatment starts in Year 2. Approximately half of all strategies were attributed to the HIT Collaborative.

CONCLUSIONS

These results suggest that measuring implementation strategies over time is a useful way to catalog implementation of an evidence-based practice over time and across settings.

Doctors don't Do-little: a national cross-sectional study of workplace well-being of hospital doctors in Ireland

OBJECTIVES

To measure levels of occupational stress, burn-out, work-life balance, presenteeism, work ability (balance between work and personal resources) and desire to practise in trainee and consultant hospital doctors in Ireland.

DESIGN

National cross-sectional study of randomised sample of hospital doctors. Participants provided sociodemographic data (age, sex), work grade (consultant, higher/basic specialist trainee), specialty, work hours and completed workplace well-being questionnaires (Effort-Reward Imbalance (ERI) Scale, overcommitment, Maslach Burnout Inventory) and single item measures of work ability, presenteeism, work-life balance and desire to practise.

SETTING

Irish publicly funded hospitals and residential institutions.

PARTICIPANTS

1749 doctors (response rate of 55%). All hospital specialties were represented except radiology.

RESULTS

29% of respondents had insufficient work ability and there was no sex, age or grade difference. 70.6% reported strong or very strong desire to practise medicine, 22% reported good work-life balance, 82% experienced workplace stress, with effort greatly exceeding reward, exacerbated by overcommitment. Burn-out was evident in 29.7% and was significantly associated with male sex, younger age, lower years of practice, lower desire to practise, lower work ability, higher ERI ratio and greater overcommitment. Apart from the measures of work ability and overcommitment, there was no sex or age difference across any variable. However, ERI and burn-out were significantly lower in consultants than trainees.

CONCLUSIONS

Hospital doctors across all grades in Ireland had insufficient work ability, low levels of work-life balance, high levels of work stress and almost one-third experienced burn-out indicating suboptimal work conditions and environment. Yet, most had high desire to practise medicine. Measurement of these indices should become a quality indicator for hospitals and research should focus on the efficacy of a range of individual and organisational interventions for burn-out and occupational stress.

"Do as we say, not as we do?" the lifestyle behaviours of hospital doctors working in Ireland: a national cross-sectional study

BACKGROUND

This study was conducted to assess the lifestyle behaviours of a national sample of hospital doctors working in Ireland. We also sought to compare the prevalence of these behaviours in doctors to the general Irish population.

METHODS

This was a national cross-sectional study of a randomised sample of hospital doctors working in Irish publicly funded hospitals and residential institutions. The final cohort consisted of 1749 doctors (response rate of 55%). All hospital specialties were represented except radiology. The following data were collected: sociodemographic data (age, sex), work grade (consultant, trainee) average hours worked over a two-week period, specialty and lifestyle behaviours (smoking, alcohol, physical activity). Lifestyle data for the general population was provided by the Healthy Ireland 2015 study.

RESULTS

Half of participants were men (50.5%). Just over half of the sample were consultants (54.3%), with 45.7% being trainees. 9.3% of doctors surveyed were smokers, 88.4% consumed alcohol and 24.5% were physically inactive. Trainees were more likely to smoke and be physically inactive when compared to consultants. Smoking rates amongst doctors were lower than the general population (9.3% -v- 23%). Doctors were more likely to consume alcohol than the general population (88.4% -v- 71.7%) but less likely to engage in binge drinking on a typical drinking occasion (12.8% -v- 39.5%). Doctors were more compliant than the general population with minimum exercise targets (75.5% -v- 70.5%), but less likely to engage in health enhancing physical activity (19.1% -v- 33%).

CONCLUSIONS

While the prevalence of health behaviours amongst hospital doctors in Ireland compares favourably to the general population, their alcohol consumption and engagement in health enhancing physical activity suggest room for improvement. Continued health promotion and education on the importance of personal health behaviours is essential.

Therapeutic alternatives for supporting GPs to deprescribe opioids: a cross-sectional survey

Background

GPs are central to opioid strategy in chronic non-cancer pain (CNCP). Lack of treatment alternatives and providers are common reasons cited for not deprescribing opioids. There are limited data about availability of multidisciplinary healthcare providers (MHCPs), such as psychologists, physiotherapists, or dietitians, who can provide broader treatments.

Aim

To explore availability of MHCPs, and the association with GP opioid deprescribing and transition to therapeutic alternatives for CNCP.

Design & setting

Cross-sectional survey of all practising GPs (N = 1480) in one mixed urban and regional Australian primary health network.

Method

A self-report mailed questionnaire assessed the availability of MHCPs and management of their most recent patient on long-term opioids for CNCP.

Results

Six hundred and eighty-one (46%) valid responses were received. Most GPs (71%) had access to a pain specialist and MHCPs within 50 km. GPs' previous referral for specialist support was significantly associated with access to a greater number of MHCPs (P = 0.001). Employment of a nurse increased the rate ratio of available MHCPs by 12.5% (incidence rate ratio [IRR] 1.125, 95% confidence interval [CI] = 1.001 to 1.264). Only one-third (32%) of GPs reported willingness to deprescribe and shift to broader CNCP treatments. Availability of MHCPs was not significantly associated with deprescribing decisions.

Conclusion

Lack of geographical access to known MHCPs does not appear to be a major barrier to opioid deprescribing and shifting toward non-pharmacological treatments for CNCP. Considerable opportunity remains to encourage GPs' decision to deprescribe, with employment of a practice nurse appearing to play a role.

Fairness in drug prices: do economists think differently from the public?

Using dual-entitlement theory as the guide, we conducted a survey of economists from the National Bureau of Economic Research asking them a series of questions about the fairness of drug prices in the United States. Public opinion surveys have repeatedly shown that the public perceives drug prices to be unfair, but economists trained in laws of supply and demand may have different perceptions. Three hundred and ten senior economists responded to our survey. Forty-five percent agreed that drug prices were unfair when people, specifically low-income individuals, could not afford their prescription medications. Sixty-five percent oppose a dollar threshold, or upper limit, on drug prices. The economists recommend the most promising policy change would be to provide the government additional negotiating power and price controls would moderately impact investment in pharmaceutical research and development.

Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict

OBJECTIVE

In the health care sector, intercollegial conflict is inevitable. Such conflict may have an adverse effect on employee turnover, workplace morale, and patient safety and care. Conversely, skillful management of conflict may result in beneficial change and improvement. Improved conflict management (CM)/dispute resolution (DR) knowledge for health care professionals (HCPs) has been shown to reduce the negative impacts of conflict. This study aimed to determine whether HCPs feel equipped to manage collegial workplace conflict and whether they feel there is a need for CM training.

METHODS

An electronic survey was developed to determine the attitudes, experience, and background training HCPs have had with CM, as well as whether respondents felt they needed CM/DR training. The survey was emailed to 660 HCPs in 2013 at Sunnybrook Health Sciences Centre, Toronto, Ontario.

RESULTS

The response rate was 46% (303 of 660). Of 303 respondents, 128 (42%) reported previous formal training in CM/DR, but only 80 of 303 (26%) felt adequately trained to manage conflict and resolve disputes in the workplace, with 59% believing they need more conflict training. Among respondents, 76% wanted to see these skills incorporated into their own career training opportunities, but only 34% were aware of courses available to improve their CM/DR skills, and 50% stated they would be interested in taking such courses; 79% wanted to see these skills incorporated into medical school curricula.

CONCLUSION

This needs assessment survey found that most HCPs did not believe that they have adequate training to manage workplace conflict comfortably, and they felt more training is needed in CM/DR.

The Effect of Varying Incentive Amounts on Physician Survey Response

A major challenge with surveying physicians is low response. In this article, we present results of an experiment conducted to determine the optimal monetary incentive amount for gaining response from physicians to a short screener survey. Sampled physicians were randomly assigned to three prepaid cash incentive conditions (US$2, US$5, US$10) compared to a control (US$0). This study found using any incentive increased response versus no incentive. The US$10 incentive produced the highest response and was significantly greater than the US$2 incentive group. However, we did not find a statistical difference between the $5 and US$10 incentives or between the US$2 and US$5 incentives. In addition, any incentive amount increased the likelihood of early response compared to no incentive. This study builds on previously mixed results about the effects of various incentive amounts and effect on early survey response. These findings provide practical advice for researchers surveying physicians.

Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

Background

Primary-care providers may contribute to the use of low-value cancer screening.

Objective

We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening.

Patients and methods

This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening).

Results

Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC).

Discussion

While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request.

Conclusion

More work appears to be needed to help providers to discuss and recommend screening that aligns with value.

Testing the Impact of Mixed-Mode Designs (Mail and Web) and Multiple Contact Attempts within Mode (Mail or Web) on Clinician Survey Response

OBJECTIVE

To compare response rate and nonresponse bias across two mixed-mode survey designs and two single-mode designs.

DATA SOURCES

This experiment was embedded in a clinician survey of knowledge and attitudes regarding HPV vaccination (n = 275).

STUDY DESIGN

Clinicians were randomly assigned one of two mixed-mode (mail/web or web/mail) or single-mode designs (mail-only/web-only). Differences in response rate and nonresponse bias were assessed.

PRINCIPAL FINDINGS

Using a multiple-contact protocol increased response, and sending a web survey first provided the more rapid response. Overall, the mixed-mode survey designs generated final response rates approximately 10 percentage points higher than their single-mode counterparts, although only the final response differences between the mail-only and web/mail conditions attained statistical significance (32.1 percent vs. 48 percent, respectively; p = .005). Observed differences did not result in nonresponse bias.

CONCLUSIONS

Results support mixing modes of survey administration and web-based data collection in a multiple contact survey data collection protocol.

Opinions, practice patterns, and perceived barriers to lung cancer screening among attending and resident primary care physicians

Introduction

The US Preventive Services Task Force recommended annual lung cancer screening with low-dose computed tomography (LDCT) for high-risk patients in December 2013. We compared lung cancer screening-related opinions and practices among attending and resident primary care physicians (PCPs).

Methods

In 2015, we conducted a 23-item survey among physicians at a large academic medical center. We surveyed 100 resident PCPs (30% response rate) and 86 attending PCPs (49% response rate) in Family Medicine and Internal Medicine. The questions focused on physicians’ opinions, knowledge of recommendations, self-reported practice patterns, and barriers to lung cancer screening. In 2015 and 2016, we compared responses among attending versus resident PCPs using chi-square/Fisher’s exact tests and 2-samples t-tests.

Results

Compared with resident PCPs, attending PCPs were older (mean age =47 vs 30 years) and more likely to be male (54% vs 37%). Over half of both groups concurred that inconsistent recommendations make deciding whether or not to screen difficult. A substantial proportion in both groups indicated that they were undecided about the benefit of lung cancer screening for patients (43% attending PCPs and 55% resident PCPs). The majority of attending and resident PCPs agreed that barriers to screening included limited time during patient visits (62% and 78%, respectively), cost to patients (74% and 83%, respectively), potential for complications (53% and 70%, respectively), and a high false-positive rate (67% and 73%, respectively).

Conclusion

There was no evidence to suggest that attending and resident PCPs had differing opinions about lung cancer screening. For population-based implementation of lung cancer screening, physicians and trainees will need resources and time to address the benefits and harms with their patients.

Potential Strategies to Achieve Universal Influenza Vaccination for Children: Provider Attitudes in Two States

OBJECTIVE

Childhood influenza vaccination rates remain suboptimal. Provider perceptions on strategies to achieve universal vaccination are needed. We assessed the perceptions and attitudes of primary care providers across 2 states regarding 2 strategies to potentially bolster rates: centralized reminder/recall (C-R/R), such as reminder/recall (R/R) notices from state immunization registries, and influenza vaccination by complementary community vaccinators (CCVs), such as retail pharmacies, schools, and health departments.

METHODS

We sent a mailed survey to a representative sample of providers across Colorado and New York. Questions addressed R/R activities for influenza vaccine, preferences and attitudes about the health department sending C-R/R notices for influenza vaccine, and attitudes about CCVs. Bivariate analyses assessed provider perceptions and compared perceptions by state.

RESULTS

The overall response rate was 56% (n = 590/1052). Twenty-two percent of providers in Colorado and 33% in New York performed practice-based R/R for all patients during the 2015-16 influenza season. Eighty-one percent of providers in both states preferred the health department or had no preference for who sent C-R/R notices for influenza vaccine to their patients; most preferred to include their practice names on C-R/R messages. Many providers in both Colorado (75%) and New York (46%, P < .001) agreed that their patients like the option of having CCVs where children can receive influenza vaccine. Some providers expressed concerns regarding potential loss of income and/or difficulty documenting receipt of influenza vaccine at CCVs.

CONCLUSIONS

Most providers support C-R/R, and many support CCVs to increase influenza vaccination rates. Collaborations between traditional primary care providers and CCVs might boost coverage.